ERISA Appeal Fact Sheet

Are You Really Filing an ERISA Appeal or Just An Appeal to an ERISA Plan?

Maximum Reimbursement through Compliance with ERISA Appeals

It has come to our attention that there has been a lot of confusion among health care reimbursement professionals and industry leaders as to the significant difference between a correct, valid and compliant ERISA Appeal and a mere Appeal to a ERISA Plan.

A valid and compliant ERISA appeal will ensure maximal benefit reimbursement or recovery for denied benefit claims. which a claimant is legally entitled to, under the relevant plan provisions following federal law, ERISA claim regulations, in accordance with the United States Supreme Court unanimous ruling in Aetna v. Davila.

A mere or standard Appeal to an ERISA Plan without specific ERISA compliance is a non-ERISA appeal to an ERISA plan, which may or may not result in optimal reimbursement or recovery for the denied benefits claim from an ERISA plan.

In accordance with DOL ERISA FAQ from U.S. Department of Labor (DOL), as published on their website, a mere or standard appeal to an ERISA plan without a valid ERISA assignment of benefits is not a grant of authority to act on a claimant’s behalf in pursuing and appealing a benefit determination under a plan (DOL ERISA FAQ B2), while an ERISA appeal with proper ERISA assignment of benefits will have complete authority and rights under ERISA on a claimant’s behalf to pursue complete document disclosure and maximal benefits under a plan (DOL FAQ B3). DOL ERISA FAQ’s <http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>

Unfortunately, as a matter of fact and as matter of law, most healthcare reimbursement and/or recovery professionals or consultants are confused on the definition of an ERISA plan and ERISA appeal in believing that ERISA covers only self-insured plans but not-fully-insured/funded health plans (“through purchase of insurance”). Nearly 170 million individuals are covered under ERISA in US currently.

ERISA law governs both self-insured and fully-insured/funded ("through purchase insurance") health plans sponsored by employers in private sector. ERISA statutory definition, 29USC1002, from the U.S. Code Online via GPO Access:

<http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite:+29USC1002>

In accordance with the United States Supreme Court unanimously ruling in ERISA judicial appeals, Aetna v. Davila, 06/21/2004, any appeal and lawsuit seeking for benefits payment from an ERISA plan falls completely (100%) within the scope of the ERISA, and all state laws are completely (100%) preempted, invalidated and superseded by ERISA.

"We hold that respondents’ causes of action, brought to remedy only the denial of benefits under ERISA-regulated benefit plans, fall within the scope of, and are completely pre-empted by, ERISA §502(a)(1)(B), and thus removable to federal district court. The judgment of the Court of Appeals is reversed, and the cases are remanded for further proceedings consistent with this opinion. It is so ordered."Aetna v. Davila, http://www.law.cornell.edu/supct/html/02-1845.ZS.html

ERISA Laws and Facts, Guidance from DOL, only if an appeal has complied with all of these ERISA regulations and DOL guidance, it is an ERISA appeal, otherwise, your appeal is just a standard appeal to an ERISA plan.

New Federal Claim Regulation<http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>, ERISA Claim Reg.

<http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>

Benefit Claims Procedure Regulation (DOL ERISA FAQ)

<http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>

Summary Plan Description

Regulations<http://www.dol.gov/ebsa/regs/fedreg/final/2000029765.htm>

SPD Laws

<http://www.dol.gov/ebsa/regs/fedreg/final/2000029765.htm>

Patient's Rights Claims Procedure Regulation (Fact Sheet)

<http://www.dol.gov/ebsa/newsroom/fs112000.html>

CRC, Claims Recovery Company, LLC, www.crcclaim.com<http://www.crcclaim.com/>, is dedicated to assisting health care providers and employee benefit plans with voluntary compliance to avoid costly and lengthy litigations and to curb health care costs in accordance with U.S. Supreme Court ruling in Aetna v. Davila, and CRC’s advocacy for voluntary compliance was inspired by American Benefits Council’s advocacy for ERISA appeals by health care providers. “The Council's members represent the entire spectrum of the private employee benefits community and either sponsor directly or administer retirement and health plans covering more than 100 million Americans”.

Supreme Court Ruling on Health Care Claims Raises Important Policy Issues: American Benefits Council Responds to Critics of Today's Davila, Calad Rulings:

"ERISA is intended to protection patients, not enrich plaintiffs' attorneys. If the objective is to ensure healthy and safe outcomes for patients, then certainly efficient review of claims disputes under ERISA, not inviting litigation, is the way to go," Klein added.” (Emphasis added)  http://www.americanbenefitscouncil.org/newsroom/pr04-32.cfm

Therefore, as a matter of law and as a matter of fact, a mere, standard appeal to an ERISA plan is not an ERISA appeal to an ERISA plan.