ERISA can cover benefit claims for disability, health, life insurance, and a wide variety of other benefits provided by ERISA plans. What does it take to be covered involves eligibility for benefit coverage. When coverage ends can involve a continuation of coverage claims.
Both beginning and ending employment can involve key coverage issues. ERISA comes
into play in a wide variety of circumstances and with a cast of different players with a range
of responsibilities. Some of the familiar roles are plan sponsor, plan administrator, claims administrator, beneficiary, participant, and alternate payee.
ERISA can cover healthcare benefit claims. Typical issues involve:
Does the ERISA plan provide coverage?
Does the plan exclude or limit coverage?
Does the particular procedure require pre-approval?
Is the admission procedure medically necessary under the plan’s definition?
Is it experimental or investigational?
Sometimes the beneficiary gets bills from doctors or hospitals for services that have not been paid. Sometimes insurers later decide they mistakenly paid a claim and back charge the providers. In short, health benefit claim denials can fall on the shoulders of people who counted on coverage but are least able to deal with them.
Divorce proceedings and disputes can involve ERISA plans. Plans must identify the beneficiary of death or pension benefits. Plans follow the “plan documents rule” to simplify administration. Finding the documentation identifying the designated beneficiary can present problems.
Whether a divorce decree qualifies a qualified domestic relations order or “QDRO"
can be a thorny question.
Even after funds have been distributed to a beneficiary,
the entitlement to the distributed funds can be contested in the state courts.
Accidental death and dismemberment claims concern not primarily whether death or disability occurred but why. Defendants invoke exclusions like alcohol or suicide exclusions but hastily, without having done an adequate fact investigation first.
Mr. Sullivan is a sole practitioner. He was born and raised in Boston, MA. He graduated from B.C. High and upon graduation entered the seminary of the Jesuit order. He graduated from Boston College and studied in Germany. There he obtained a degree in philosophy. He speaks fluent German.
He obtained his J.D. from Northeastern School of Law in Boston and moved to Florida, where he has practiced law since 1976. His practice focuses on representing ERISA claimants. His practice has focused on ERISA claimants since 1987.
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Photo credit: Kim Seng