Resources on Benefit Denials and Appeals Under ERISA
Most employer-sponsored group health insurance is subject to the federal Employee Retirement Income Security Act of 1976 (ERISA). Regulations pursuant to that law govern the time frames for health plans to decide whether or not to pay benefits under a claim, what information plans must disclose when they decide to deny benefits, and the process for handling appeals within a health plan (internal appeals). These rules apply both to plans that are “fully-funded” (that is, a health insurer bears the risk for claims) and plans that are “self-funded” (that is, the employer bears the risk for employee’s claims). For plans that are fully-funded, state laws may apply in addition to ERISA and may give consumers additional rights to appeal to an independent entity outside of their health plan (external appeals).
The interaction between state and federal law in the area of employee health benefits is extremely complicated and often misunderstood. This page provides a broad overview of the federal law and regulations about benefit denials and appeals, some tips about handling internal appeals, and information about some key court cases about the interaction between state and federal laws and consumers’ rights to go to court under ERISA.
Information about the ERISA Claims and Appeal Regulations
On July 1, 2002, the U.S. Department of Labor, under authority granted by the Employee Retirement Income Security Act of 1974 (ERISA), put into effect new regulations covering claims procedures for employer-based health plans The regulations contain new rights and disclosure provisions important to consumers with disputed claims. The Affordable Care Act affords consumers a number of additional rights to appeal health plan decisions. The new rules, effective September 23, 2010, apply to “new” health plans (not grandfathered health plans). The Departments of Labor, HHS, and Treasury are likely to issue further guidance concerning appeal rights in 2011.
Here are the 2002 rules that will still apply to plans that don’t qualify as “new” plans:
Here is information about the appeal rights applying to new plans under the Affordable Care Act, from the U.S. Department of Labor:
See the Employee Benefits Security Administration section of the U.S. Department of Labor website for fact sheets, model notices in English and Spanish, and further updates.
Families USA has produced a brief fact sheet on your right to appeal, Ensuring the Right to Appeal Health Plan Decisions.
Analyses and the Full Text of Key ERISA Decisions
Aetna v. Davila and Cigna v. Cala Decision
Conference Call Materials on Aetna v. Davila and Cigna v. Cala Decision
Analysis of Rush v. Moran
Rush Prudential HMO v. Moran Decision
Analysis of Corporate Health v. Texas Department of Insurance (citing Rush v. Moran)
Corporate Health Decision
Analysis of Connecticut General Life v. Insurance Commissioner for the State of Maryland (citing Rush v. Moran) Connecticut General Life Decision
Kentucky Association of Health Plans v. Miller Decision
Conference Calls on ERISA
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