If you are seeking ERISA-covered benefits through your employer’s insurance, it is advisable to contact a Texas ERISA lawyer to help you get the benefits you are entitled to. Texans may seek different types of benefits through their employer-provided insurance, including long-term disability, life insurance, health care, and others.

In Texas, employer-provided insurance accounts for more than half of all health insurance coverage provided to the non-elderly population in the age group of between 0 and 64.

Let an experienced Texas ERISA lawyer help you receive the benefits you deserve. At J. Price McNamara ERISA Insurance Claim Attorney, we provide reliable and responsive legal representation to clients dealing with ERISA-related issues throughout Texas.

We are not afraid to stand up to big-name insurance companies and fight for the clients’ needs and best interests in out-of-court disputes and ERISA litigation. Get immediate assistance with your ERISA claim with a free consultation with J. Price McNamara. Call (713) 300-0462 now.

Do You Qualify for ERISA?

There is no such thing as “qualifying” for the Employment Retirement Income Security Act (ERISA). You can be a participant under an ERISA plan depending on how you receive your benefit plan coverage. If your employer, union, or trade organization sponsors a benefit plan, ERISA likely applies unless you work for a government entity.

ERISA governs the vast majority of all benefit plans provided by employers in the private sector.

What Does ERISA Oversee?

ERISA is a federal law enacted in 1974 that sets minimum requirements for employee benefits plans.

Under 29 U.S.C. § 1002, ERISA-covered employee benefits plans can fall into two categories:

1. Pension plans, including the 401(k) plan, 403(b) plan, SIMPLE plan, and others.
2. Welfare benefit plans, which include all other employer-sponsored benefit plans that do not meet the definition of a pension plan. Welfare benefit plans refer to long-term disability insurance, life insurance, accidental death and dismemberment insurance, health insurance, and others.

If you seek benefits through an employer-sponsored plan in Texas, chances are that the plan must follow ERISA guidelines.

Contact an ERISA lawyer if you pursue benefits through your employer-provided insurance plan.

What Does ERISA Coverage Exclude?

Not all benefit plans fall under ERISA, as the federal law explicitly excludes specific plans from ERISA coverage.

Here’s a list of benefit plans that do not have ERISA coverage:

• Government-sponsored plans
• Church plans unless they meet the requirements outlined in 26 CFR § 1.410(d)-1
• Workers’ compensation benefits
• Adoption assistance plans
• Tuition reimbursement plans
• Benefit plans maintained outside of the U.S. to benefit non-residents
• Unfunded excess benefit plans

If you are not sure whether ERISA covers the benefit plans your employer provides, speak with an attorney.

What Are the Fiduciary Duties Under ERISA?

ERISA law requires fiduciaries, including plan administrators, to comply with the following duties when handling claims or distributing plan assets:

1. The duty of loyalty. Fiduciaries must act in the best interests of the participants and beneficiaries of the plan. If the fiduciary has a conflict of interest, they must put the interests of the participant and beneficiary first. If necessary, the fiduciary may retain an independent fiduciary to handle the matter when there is a conflict of interest.
2. The duty of prudence. Under 29 U.S.C. § 1104, fiduciaries must act with a reasonable degree of skill, care, prudence, and diligence. The duty of prudence refers to a fiduciary’s ability to make decisions and take the degree of care that a reasonably prudent person would exercise. If a fiduciary cannot exercise the duty of prudence, it must seek the assistance of or delegate the matter to another competent fiduciary.
3. The duty to diversify. A fiduciary who is responsible for investing plan assets is required to diversify the plan investments to reduce the risk of unexpected losses unless diversifying the investments would not be reasonable or prudent under the given circumstances.
4. The duty to follow the plan’s documents. A fiduciary must follow the terms and conditions of the plan’s documents unless doing so would violate any provisions of the Employee Retirement Income Security Act (ERISA). The duty could also extend to certain ancillary documents, including collective bargaining agreements documents.

If you believe that your employer’s insurance company or the plan administrator breached any of the above duties when handling your ERISA-covered claim, do not hesitate to consult a lawyer.

Can You Hold Your Employer Responsible for Breaching a Fiduciary Duty?

Yes, if your employer owes you any fiduciary duties under the Employee Retirement Income Security Act, you may be able to hold your employer responsible for breaches of fiduciary duties.

Some of the most common types of breaches that occur in ERISA-related cases include:

• Failure to make prudent decisions when managing plan assets
• Failure to act in the best interests of the participant or beneficiary
• Conflict of interest
• Failure to respond to claims on time
• Failure to follow plan requirements
• Failure to diversify plan investments

If you believe that your employer or another fiduciary breached their duties owed to you, it is vital to contact an experienced attorney to help you sue the liable party for the breach of duty and recover damages.

How Do Insurance Companies Investigate ERISA-Related Claims?

When seeking benefits covered under ERISA, the investigation process looks like this:

1. You submit your claim. Once you submit your claim, the insurance company will launch its investigation.
2. The insurer investigates your claim. During the investigation, the insurer will review all relevant pieces of evidence to determine whether to approve or deny the claim. For example, if you are seeking long-term disability benefits, the insurance company is likely to review your medical records and testimony from your doctor.
3. The insurer approves/denies the claim. Once the investigation is complete, the insurance company will issue its decision. The insurer can either approve or deny your claim. Under ERISA law, insurance companies and plan administrators are allowed to take up to 105 days (more than three months) to decide the claimant’s initial claim.
4. The insurer provides a denial letter. If the insurance company denies your claim, you will receive a letter notifying you of the denial. The denial letter must contain a written explanation of the denial as well as provide instructions on how you can appeal the denial of your claim.

If an insurance company denied your ERISA-covered claim, you should contact a skilled attorney as soon as possible. Your Texas ERISA lawyer will help you appeal the denial of your claim and, if necessary, protect your rights during ERISA litigation.

What You Need to Know About Appealing the Denial of Your ERISA Claim

Under ERISA regulations, people seeking ERISA-covered benefits have to exhaust their administrative remedies before filing a lawsuit against the insurance company. Appealing directly to the insurance company is usually enough to satisfy the requirement.

When filing an appeal to the insurance company, support it with as much evidence as possible. Your ERISA lawyer will help you strengthen your appeals case by gathering all available evidence to improve your chances of success.

One of the ERISA provisions that many people are not aware of is that you may not be allowed to submit any new evidence during a lawsuit. In other words, the judge will be limited to the evidence that was brought by the claimant when filing their initial claim and during the administrative appeals process.

For this reason, we cannot overstate the importance of collecting all the evidence that may help you succeed. You should seek the legal assistance of an experienced ERISA lawyer to help you prepare a strong case when filing an appeal.

ERISA requires insurance companies to give claimants a certain amount of time to appeal the denial of their ERISA-covered claim. The amount of time to appeal depends on the type of benefit at issue in the claim.Your attorney will review the terms of your benefit plan to determine the best strategy to succeed in appealing the denial of your claim.

If the insurance company decides to approve your appeal, you may receive the requested benefits shortly after the approval. However, if your appeal does not succeed, you may bring a lawsuit against the insurer and/or plan administrator.

What You Need to Know About ERISA Litigation

As mentioned earlier, you have a right to bring a civil lawsuit against defendants in ERISA litigation once you have exhausted all of your administrative remedies, including filing an appeal directly to the insurance company that denied your claim.

Here are several things you should know when filing a lawsuit against the insurance company:

1. Since ERISA is a federal law, you will sue the insurance company in federal court;
2. A judge will decide how to resolve your ERISA-related case, rather than a jury;
3. You may not submit any new evidence during ERISA litigation because courts are limited to the evidence you have already submitted to the insurer;
4. You most likely cannot testify in court during your ERISA-related case; and
5. The insurance company may discourage you from hiring an attorney to represent you in court.

You should always contact a skilled lawyer after you receive a denial of your claim. Your lawyer will help you file an appeal and represent your rights in front of the judge. It’s actually best to call our Texas ERISA lawyers before you apply for benefits so that we can submit it properly. Definitely call us as soon as you receive the first denial letter from the insurer.

Many claimants hesitate to file lawsuits because they worry that doing so could cause them to lose their job. But can your employer fire you for seeking ERISA-covered benefits? The short answer is “no.” Employers may not fire or take any other adverse employment actions against employees who seek benefits under ERISA-covered plans. If your employer retaliated against you for seeking ERISA-covered benefits or filing a civil lawsuit, call a lawyer immediately.

Do You Need a Texas ERISA Lawyer?

There are many reasons to hire an ERISA lawyer when seeking benefits covered under ERISA, especially if the insurer denies your initial claim.

Consider the following reasons to retain a skilled lawyer who has experience in handling ERISA-related cases:

1. Your lawyer will review your unique situation and help you understand your options;
2. Your lawyer will outline all of your rights and obligations under your ERISA-covered plan;
3. Your lawyer will help you determine if any fiduciary, including the plan administration, breached any duties owed to you;
4. Your lawyer will help you gather all available evidence and documentation to build a strong case;
5. Your lawyer will make sure that you comply with all the applicable requirements and rules under ERISA;
6. Your lawyer will exhaust all of your administrative remedies to help you get the benefits to which you are entitled;
7. Your lawyer will advocate for your rights when presenting your case to a judge in federal court; and
8. Your lawyer will ensure that you receive a fair amount of benefits under your ERISA-covered plan.

Contact a Texas ERISA lawyer to help you effectively handle your ERISA-based claim and get the benefits you deserve under your employer-sponsored plan. Without the right legal assistance, you risk losing the benefits that you need and that you deserve under the law and your employer-sponsored coverage. Insurers are often more responsive when a claimant has legal representation.

Consult a Texas ERISA Lawyers Today

Schedule a free initial consultation with J. Price McNamara ERISA Insurance Claim Attorney. We can help you seek the benefits the law gives you under your ERISA-covered plan. Mr. McNamara has successfully represented numerous clients in Houston and throughout Texas.

Call (713) 300-0462 or complete our contact form for a free, no-obligation case review. We work on a contingency basis, so if you don’t win your case, you will owe us nothing. Our law firm is ready to help with complex ERISA matters.