Frequently Asked Questions
Disability benefit denials come in two forms: ERISA and NON-ERISA plans. Disability benfit denials are different than Social Security Benefit Denials.
More about Disability Benefit Denials:
More about Disability Benefit Denials:
- NON-ERISA Plans. A Non-ERISA plan is a plan not provided to you by your employer. For instance, you contact an insurance company directly and pay for a disability plan on your own. Or, you work for a governmental entity such as a school board, and the school offers a discount plan that is not sponsored by the school board. A Non-ERISA plan is treated more like a breach of contract claim, although some of the same law applies to a Non-ERISA case as an ERISA case.
- What is the Employee Retirement Income Security Act? ERISA is the acronym for the Employee Retirement Income and Securities Act. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.
- The goal of ERISA is to protect employee benefit plans, such as retirement and health care plans by providing insurance benefits and, setting requirements for the plan. It also provides a set of rules for employees and "plan fiduciaries" to follow with respect to the management of these plans, including grievance procedures, administrative procedures, and procedures for funding the plan.
- In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or plans which are maintained solely to comply with applicable workers compensation, unemployment, or disability laws. ERISA also does not cover plans maintained outside the United States primarily for the benefit of nonresident aliens or unfunded excess benefit plans.
- Our office handles cases that arise from Short-term and Long-term disability benefit plans. To help us establish whether you have a claim you should determine first whether your potential claim arises from a benefit plan. You may also need to know who sponsor's your plan (Plan Sponsor), who administers your plan (Plan Administrator) and who acts as the plan's Fiduciary.
- The following sections will help you understand how to determine this information if you do not have a copy of your Plan (documents describing your benefits) or your Summary Plan Description which should contain "the name and type of administration of the plan;" registered agent information; who the administrator of the plan is including their address; the "name, titles, and addresses of any trustee or trustees;" "the plan's requirements respecting eligibility for participation and benefits;" "circumstances that result in disqualification or loss of benefits;" the end date of the plan; and "procedures for filing benefit claims."
- What is a benefit plan? A benefit plan is ". . .any plan, fund, or program which was established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise (A) medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, death or unemployment or vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services"
- The plans are covered if the plan was ". . . established or maintained by and employer engaged in commerce or in any industry or activity affecting commerce or by any employee organization or organizations representing employees engaged in commerce or in any industry or activity affecting commerce or by both."
- Not all plans are covered by ERISA. For example, Section 4(b) says that ERISA does "not apply to any employee benefit plan if . . . [the] plan is a governmental plan, . . . a church plan with respect to which no election has been made under section 410(d) of the Internal Revenue Code is maintained solely for the purpose of complying with applicable workmen's compensation claws or unemployment compensation or disability insurance laws is maintained outside of the United States primarily for the benefit of persons substantially all of whom are nonresident aliens or is an excess benefit plan and is unfunded." However, you may have a contract action even if your plan is not an ERISA plan. You should contact our office or consult with an attorney in your area to further determine whether a claim exists.
- Who is Covered by ERISA? ERISA tells us that an employee may be covered under ERISA if the employee is or was a participant of a plan. A participant is "any employee or former employee of an employer, or any member or former member of an employee organization, who is or may become eligible to receive a benefit of any type from an employee benefit plan which covers employees of such employer or members of such organization, or whose beneficiaries may be eligible to receive any such benefit."
- A beneficiary is "a person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit thereunder."
- Who is an employer? An Employer is "any person acting directly as an employer, or indirectly in the interest of an employer, in relation to an employee benefit plan; and includes a group or association of employers acting for an employer in such capacity."
- An employer can also be an organization such as " any labor union or any organization of any kind, or any agency or employee representation committee, association, group, or plan, in which employees participate and which exists for the purpose, in whole or in part, of dealing with employers concerning an employee benefit plan, or other matters incidental to employment relationships; or any employee's beneficiary association organized for the purpose in whole or in party of establishing such a plan."
- Who is a Plan Administer? A plan administrator is "a person specifically so designated by the terms of the instrument under which the plan is operated" and where an "administrator is not so designated, the plan sponsor or in the case of a plan for which an administrator is not designated and a plan sponsor cannot be identified, such other person as the Secretary may by regulation prescribe."
- Who is a Plan Sponsor? A plan sponsor is "the employer in the case of an employee benefit plan established or maintained by a single employer, the employee organization in the case of a plan established or maintained by an employee organization, or in the case of a plan established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan."
- What is a Fiduciary? a fiduciary with respect to a plan is a person who "exercises any discretionary authority or discretionary control respecting management of such plan or exercises any authority or control respecting management or disposition of its assets; renders investment advice for a fee or other compensation, direct or indirect, with respect to any moneys or other property of such plan, or has any authority or responsibility to do so, or; has any discretionary authority or discretionary responsibility in the administration of such plan . . ." and includes any person the "named fiduciary designates other than the named fiduciary to carry out fiduciary responsibilities other than trustee responsibilities under the plan."
- The Employee Benefits Security Administration (ESBA) is the Department of Labor's subordinate organization that oversees ERISA. According to the ESBA's mission statement, it is the ESBA's goal to: assist workers in getting the information they need to exercise their benefit rights; assist plan officials to understand the requirements of the relevant statutes in order to meet their legal responsibilities; develop policies and regulations that encourage the growth of employment-based benefits; deter and correct violations of the relevant statutes through strong administrative, civil and criminal enforcement efforts to ensure workers receive promised benefits. The DOL promulgates regulations that help employees, legal professionals, law makers, judges, and employers to fully comprehend their responsibilities under ERISA. The regulations also expand penalties and further the statutory requirements under ERISA.
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