Does ERISA Apply To Me?

The purpose of the Employee Retirement Income Security Act (ERISA) is to protect employees who are counting on retirement benefits or pensions that their employer promised them.

ERISA sets guidelines and rules for how employee retirement funds must be managed and establishes strict guidelines for when and how employees earn a non-forfeitable interest in promised pension benefits.

It also provides a remedy for employees if their pension funds are mismanaged, and the Pension Benefit Guaranty Company provides a source of funding to pay out benefits in the event that an employer fails to pay out defined benefits as promised.

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The purpose of the Employee Retirement Income Security Act (ERISA) is to protect employees who are counting on retirement benefits or pensions that their employer promised to provide after they leave employment. ERISA includes requirements for maintaining and paying out benefits as defined by retirement plans and benefit plans (e.g., long-term disability insurance).

ERISA sets guidelines and rules for how employee retirement funds and benefit plans must be managed and establishes strict guidelines for when and how employees earn a non-forfeitable interest in promised pension benefits.

The ERISA law also requires plans to establish grievance and appeals processes that participants may pursue if benefit payments are disputed. It gives participants the right to sue for unpaid benefits and over plan administrators’ breaches of fiduciary duty. It also provides a remedy for employees if their pension funds are mismanaged. The Pension Benefit Guaranty Company provides a source of funding to pay benefits in the event that an employer fails to pay out defined benefits as promised.

If you have been denied pension or healthcare benefits that you were promised by a former employer, contact a South Carolina ERISA lawyer at Joye Law. Phone (888) 324-3100 or fill out our online contact form for a free and confidential claim evaluation.

Does ERISA Apply to My Benefits?

ERISA ensures that benefits that are part of an employee’s retirement or severance package are provided as promised. The language of the ERISA law refers to employer-provided benefits as “employee welfare benefit plans.” The law applies to plans established and maintained by an employer to provide benefits to current or former employees or their beneficiaries.

ERISA applies to numerous types of benefit plans:

  • Defined-benefit and defined-contribution retirement funds (pensions).
  • Insurance plans, including HMO/group insurance plans, such as health and medical care insurance.
  • 419(e) Welfare Benefits Plans, including and 419(a)(f)(6) plans.
  • Health savings accounts (HRAs) that are funded through pre-tax contributions.
  • Flexible spending accounts (FSAs).
  • Dental insurance plans.
  • Prescription drug plans.
  • Vision plans.
  • Disability insurance.
  • Long-term care insurance plans.
  • Business travel insurance.
  • Unemployment benefits.
  • Scholarship plans.
  • Housing assistance plans.
  • Training plans.
  • Vacation plans.
  • Pre-paid legal service plans.

What is ERISA Disability?

If you have a long-term disability insurance policy through your employer, it is likely governed by ERISA. Long-term disability policies are sometimes known as “ERISA disability” policies. If you leave work because of a disability, your long-term disability coverage is designed to replace some of your lost income.

The summary plan description provided to you when you signed up for an ERISA-covered benefits plan gives you a detailed overview of the plan, including how it works, what benefits it provides, how to file a claim for benefits and any limitations that may apply. If you do not still have your copy, contact the plan administrator (likely your former employer’s Human Resources department or a third party whom HR can refer you to) and request one.

A summary plan description also describes your rights and responsibilities under ERISA and your plan. Among other things, ERISA and its related rules include:

  • Requirements for processing disability benefit claims.
  • A timeline for a decision (usually within 45 days of receiving the claim, though there are reasons for extensions, which you will be notified of if invoked).
  • Your rights when a claim is denied.

It is important that your claim for benefits indicates that you meet the plan’s requirements for disability and that it is filed according to procedures defined in the plan. Make sure you keep copies of everything that is included in your application for benefits as well as all correspondence or reports to and from the plan administrator, your former employer, doctors and therapists.

If your claim is denied, the plan administrator must send you a notice, either in writing or electronically, that includes:

  • A detailed explanation of why your claim was denied. If applicable, the notice must explain why the plan disagreed with the views of a medical professional or vocational expert (including those who treated you and those whose advice was obtained by the plan), or a disability determination made by the Social Security Administration.
  • Identification of the specific plan provisions the denial is based on.
  • The plan rules, guidelines, protocols, standards, or other similar criteria relied upon in denying the claim, or a statement that such documents do not exist.
  • Notice that you are entitled to receive copies of all documents relevant to your claim for benefits, upon request and at no cost to you.
  • A description of the plan’s appeal process, including deadlines for filing an appeal, and a statement of your right to pursue your claim in court if your claim is denied on appeal.

Appealing an ERISA Disability Claims Denial

You may appeal an adverse decision by the administrator of an ERISA-covered disability benefits plan. Initially, an appeal means someone who has not seen your file previously will review your claim and, if a medical judgment is involved, will consult qualified medical professionals. The reviewer is not to consider the initial decision as they conduct their review.

When filing an appeal, you need to address any issues raised in the initial denial and/or provide additional medical information or other evidence to support your claim.

You have at least 180 days from receipt of a denial notice to file an appeal. The second review of your claim is also generally a 45-day process, with various reasons that the timeline may be extended with notification to you.

Some insurance plans require two levels of review of a denied disability claim. If your appeal is denied after the first review, the plan must allow you a reasonable period of time (but not a full 180 days) to file for the second review.

If your claim is denied again, you will receive an explanation much like after the original denial. It will also explain your additional right to appeal the decision in court. Depending on the way your plan is written, you may be able to go to court sooner, but most plans define an appeal process similar to that outlined above and require beneficiaries to complete it before filing a lawsuit.

An ERISA benefits attorney from Joye Law can help you file a claim, appeal a denial or sue for benefits you have been promised. We can help you navigate the entire claims process, and work with you to gather evidence to support your claim, including referring you to medical professionals if necessary.

What Employers are Covered by ERISA?

ERISA applies to private-sector companies that offer pension plans to employees. This includes businesses that:

  • Are structured as partnerships, proprietorships, LLCs, S-corporations and C-corporations. No matter how your employer has structured his or her business, it is covered by ERISA if it is a private entity.
  • Are nonprofit corporations. Almost all nonprofits and charitable organizations, including 501(C)(3)s, are covered by ERISA.
  • Have only one or two employees. There is no minimum number of employees that a business must have for ERISA to apply to the company.

ERISA is a very broad piece of legislation. If you work for any private employer or for any private company, then you are probably covered by ERISA.

When does ERISA not apply?

Although ERISA provides protection to people who work for most types of employers, there are a few limited exceptions, including:

  • Most governmental employers and government entities.
  • Churches, synagogues, mosques, temples.
  • Benefit plans that are maintained only for purposes of complying with workers’ compensation, disability or unemployment laws.
  • Unfunded excess benefit plans.
  • Plans that are maintained outside of the United States and that are intended primarily to benefit non-resident aliens.

What Benefits are Not Covered by ERISA?

There are a few limited exceptions and types of benefits not covered by ERISA. These exceptions include sick-pay plans and short-term disability / medical leave plans if:

  • They are paid out to individual employees
  • No employee contributions are made
  • They are paid out as part of normal payroll practice
  • The funding comes from general employer assets and not from pre-funded accounts or insurance policies.

Some types of voluntary group insurance plans in which employees pay all premiums to insurers through payroll deductions may not be covered by ERISA, if the employer does not endorse or contribute to the plan.

Contact a South Carolina ERISA Benefits Attorney

If you are covered by benefits plans subject to ERISA and your employer is denying you any covered benefits or is otherwise acting improperly in regard to your pension or benefits, it is very important that you seek legal help. ERISA aims to provide broad protection to employees, but employees must follow specific rules to take advantage of the protections available.

At Joye Law Firm, our South Carolina ERISA attorneys are here to help. The disability benefits lawyers of Joye Law Firm are committed to our clients and dedicated to South Carolina. Since 1968, our firm’s attorneys and support staff have been active in the communities of Charleston, Columbia, Myrtle Beach and Clinton, SC, providing scholarships, spearheading charity fundraising initiatives, and improving the health and well-being of people across the state.

Reach us today at (888) 324-3100 or fill out our online contact form to schedule a free consultation with one of our South Carolina ERISA disability lawyers in our Charleston, Columbia, Myrtle Beach or Clinton offices, or at a location convenient for you.

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