Frequently Asked Questions
- What is ERISA?
- What plans are covered by ERISA?
- How do I file a claim with my plan?
- I’ve filed a claim – when can I expect to hear something?
- My claim was denied – now what?
- How long will it be before I hear whether my appeal of a denial was successful?
- Can I sue the plan if it denies my claim for benefits?
- If I sue, where will my claim end up?
- Can I recover an attorneys fee if I am successful in my case?
- Who will decide my case, a judge or jury?
- How do I hire you?
What is ERISA?
ERISA, the Employee Retirement Income Security Act of 1974, was enacted by the federal government to protect the interest of participants in private employee benefit plans. ERISA requires plans to provide participants with information about plan features and funding; sets forth the legal responsibilities of those who manage and control plan assets; and requires plans to establish a fair claims process. If benefits are improperly denied, or if plan assets are mismanaged, plan participants can sue the employer or union sponsor of the plan through ERISA.
Back to TOP
What plans are covered by ERISA?
The large majority of employer- or union-sponsored disability, pension and health plans are subject to ERISA’s requirements. Although ERISA does contain a few exceptions, similar legal requirements frequently govern those plans; thus, regardless of whether you think ERISA does or does not apply to your employer’s plan, Jester & Jenkins stands ready to help you whenever you have an insurance claim or a benefit claim denied.
Back to TOP
How do I file a claim with my plan?
If you don’t have a copy of the summary plan description, request one from your plan or employer as soon as possible. ERISA not only requires plan administrators to provide you with a summary plan description, but also requires that the description clearly spells out your rights. Your summary plan description will tell you what you need to do to qualify for benefits and may require you to, for example, work a certain number of years before receiving benefits or file a claim within a certain time period of when you seek services. Your summary plan description should also spell out the procedures required to file a claim for benefits. If for some reason the information is not provided to you, notify your employer or plan administrator in writing that you have a claim and want a copy of the summary plan description.
Back to TOP
I’ve filed a claim – when can I expect to hear something?
ERISA requires plans to notify you whether it accepts or denies your claim between 45 and 60 days, depending on the type of claim, after the claim is filed, unless, because of special circumstances, the plan can notify you that additional time is needed. This notification must be provided in writing and, if the claim is denied, a detailed explanation must be included.
Back to TOP
My claim was denied – now what?
If you feel that your claim was wrongly denied, it is important to act very quickly to pursue your claim further. This is when you need to contact Jester & Jenkins. We do not recommend that you try to appeal the denial yourself. We need to work with you and your doctor in order to gather the information necessary to properly support your appeal. This could range from a doctor's statement, obtaining additional testing, a vocational report, an FCE, or other procedures. It depends on your case and you have to have the knowledge and experience to properly prepare the appeal. Your appeal is the only chance that you get to tell the insurance company why you are disabled. You have to include everything, and it's your responsibility or burden to prove that you are disabled or that you are continuing to meet the definition of disability under your plan. Do not expect the insurance company to gather the necessary information. Many disability claims are lost at this key point.
Back to TOP
How long will it be before I hear whether my appeal of a denial was successful?
In general, the claims administrator, often the insurance company, has 60 days for health claims and 45 days for disability claims to notify you in writing of its decision. The administrator can obtain extensions of an additional 60 days for health claims, and another 45 days for disability claims. Once a decision has been reached, the claims administrator must notify you in writing and point out the plan provisions that support its decision to deny your claim.
Back to TOP
Can I sue the plan if it denies my claim for benefits?
As long as you have complied with (1) the standards set forth in the summary plan description to be eligible for benefits, and (2) the procedures for filing and seeking review of your claim, you can bring an action against your plan for wrongfully denying your claim. Because ERISA claims involve a number of unique procedures, it is important to find a lawyer with solid experience successfully handing employee benefit claims. The attorneys at Jester & Jenkins offer just such experience and stand ready to help you through each and every stage of the claim process, including the initial appeal and, if necessary, filing suit.
Back to TOP
If I sue, where will my claim end up?
In general, state and federal courts have overlapping jurisdiction (concurrent jurisdiction) of ERISA claims. However, due to various federal rules, almost all claims end up in federal court. Jester & Jenkins is licensed to practice in all federal courts in Alabama, as well as before the Eleventh Circuit Court of Appeals and the United States Supreme Court. For other jurisdictions, we can associate counsel in your local area to help you pursue a valid claim.
Back to TOP
Can I recover an attorneys fee if I am successful in my case?
If you have to file suit, and you ultimately win your case, then it is possible that the trial judge may award you some, none or all of your attorney fees. It just depends on the type of claim, and it is totally up to the judge (this is known as "judicial discretion").
Back to TOP
Who will decide my case, a judge or jury?
Currently, in ERISA cases, a judge makes the decision. There is no right to a jury trial.
Back to TOP
How do I hire you?
Jester & Jenkins works on a contingency fee and/or an hourly basis, depending on the type of claim and amount of benefit involved. Contact us and we will be happy to set up an appointment for you and discuss your claim and our fee.
Back to TOP |
