Frequently Asked Questions

Exhaustion of administrative remedies is also very important under ERISA. If your ERISA benefits require you to go through certain administrative remedies in order to dispute a claim denial, then you must exhaust those remedies before you can go to court. For example, in the case of an ERISA life insurance claim, the insurance policy may require you to submit a claim within a certain number of days. If that claim is denied, then you are often required to appeal to the claims handler who denied your claim and ask them to reconsider that denial before you file a lawsuit. If you don’t go through that process or you fail to appeal within the appropriate timeframe, a court may later find that you failed to exhaust administrative remedies. This is very bad because it could be the end of the road for your claim.

Your case will very likely be dismissed by the court if exhaustion has not occurred. Although most claims will involve an initial decision and an appeal, some plans may allow additional administrative remedies that should be utilized before you can file suit. The plan can also specify the statute of limitations, so this whole process can easily cause disaster.

The ERISA benefit plan may also require sending each claim to a different entity, so it is important to know exactly what to do and what the deadlines are for each step. It is also important to know when the insurance company has missed a deadline, because you may be able to file suit and strip them of one of their biggest defenses to your claim; the arbitrary and capricious standard of review.

If ERISA does apply, finding out what the terms of the insurance policy are can prove quite difficult. ERISA benefits often involve interpreting several different documents, including global wrap plan documents, summary plan descriptions, and insurance policies or certificates of coverage. These will often have different, conflicting terms, and it is not always easy to know which set of terms the court will find to be controlling.

The other big problem here is that employers will rarely send you all the documents you need and have requested. It is also often quite difficult to know who to request these documents from in the first place. Further, many of the benefits under an employee welfare benefit plan or pension plan will be interconnected. So, if you have an ERISA disability benefits claim, you will need the ERISA life insurance policy as well because the ERISA life insurance policy premiums for that life insurance policy should be waived and coverage continued while you are disabled.

• The most typical types of ERISA-governed employee benefits that we see are disability benefits, life and AD&D insurance, pension benefits, and medical insurance benefits.
• Most people are unaware of the full extent of the group insurance benefits that are provided as part of their employee benefits package. You cannot rely on the insurance company to tell you about these additional benefits.
• It is important to note that the investigations that we conduct into these benefit packages are not limited to things you or your spouse purchased, it is also crucial to investigate what the employer paid for. A lot of people are unaware of the insurance that is provided in the employee benefits packages because the employer pays the premium.

If the benefits in question were connected to your employment, the answer is probably yes. However, if the employer was a government or church, then ERISA may not apply. Although this seems straightforward, this question can be incredibly complex.

One of our cases involved several months of litigation surrounding the question of whether a church was a church because there is some division on whether “religious entities” are considered churches. Quasi-governmental entities can lead to lengthy preliminary disputes as well. The insurance company will do everything it can to get ERISA to apply if there is even a slim chance it will work.

No. If your employer is a governmental entity, then ERISA would not apply. However, if you find yourself participating in a 457b plan because of your status as a contractor for government agencies, the answer can be less clear.

Yes. Assuming you have a private employer.

Yes. Employer-sponsored 401k plans are subject to ERISA.

Probably not. As we mentioned before, ERISA applies to your pension and employee benefits that you have as a result of your status as an employee. “Individual” Retirement Accounts are likely outside of that employment relationship.

Maybe. It depends on who your employer is. If it is a governmental entity, then no. If it is a private charitable entity? Then likely, yes.

If you have a disability insurance policy, the amounts payable will be defined in the policy itself. Individual policies typically stop paying benefits at your normal retirement age as set out by the Social Security Administration, which is based on your date of birth.

The answer depends on the terms of the insurance policy. Typically, it varies from a percentage of your pre-disability earnings to fixed monthly benefit amounts.

Due to the fact that there is no specific minimum number of people required, the number of people needed for a class action lawsuit can vary depending on the jurisdiction and the specific rules governing class actions. Generally, one or more plaintiffs can file a class action on behalf of a larger group (the class) if specific requirements are met.

To be certified as a class, the court typically considers factors such as:

Numerosity: The class must be large enough that joining all individual claims in a single lawsuit is not feasible or practical.

Commonality: The class members must have common questions of law or fact.

Typicality: The claims or defenses of the representative parties must be typical of those of the class.

Adequacy of Representation: The representative parties must fairly and adequately protect the interests of the class.

It’s important to consult the specific rules and regulations of the jurisdiction where the lawsuit is being filed, as they may have additional or different requirements. Legal advice from an attorney experienced in class action litigation, such as our team at Sinclair Law Firm, is recommended for anyone considering or involved in a class action lawsuit.

Disability benefits are paid for the length of the policy ‘maximum benefit period’ so long as you meet the policy definition of disability,and no exclusions apply. How long those benefits are paid also depends on the coverage in question, and most group policies end at either age 65 or your normal Social Security Retirement Age. Some individual Disability Policies can pay benefits even longer.