We handle ERISA § 502 claims against group health insurance policies and administrators for benefits payable under the plan, and breaches of fiduciary duty. The firm has represented countless clients in getting health plans to cover the cost of necessary services, and in forcing employers and other fiduciaries to pay the cost of services due to misrepresentations and other breaches of fiduciary duty. Recently the firm successfully represented a client who was assured by the insurer that a hospital was in-network, but after ward had his claim denied as out-of-network. The Firm demonstrated that the insurer was liable because of its misrepresentation. We also helped a client have insurance cover a costly surgery that was necessary for the client to conceive children where the insurer denied the claim as “cosmetic.” In another case, an employer switched insurance carriers while our client was receiving COBRA coverage, but never enrolled the client with the new insurer. We helped the client get the cost of her child delivery covered despite there being no binding insurance coverage at the time of delivery.
Employer provided group health insurance policies offered through your employer are usually employee benefit plans covered by ERISA. The administrator may deny coverage for a costly surgery and after-surgical treatment because it claims the treatment falls into an exclusion in the plan. In other instances, health insurers provide an approval for the treatment or procedure, only later to deny paying for the cost, leaving you with doctor and hospital expenses in the upper five figures, six figures, or in some cases even in the millions. Often, the surviving spouse of a participant with a morbid condition is left with bills which the insurer rightfully should have covered.
When your insurer refuses to pay for a treatment or surgery you already underwent, it is critical to involve an ERISA lawyer immediately. Ignoring the problem, or letting the hospital fight with the plan, will only result in the hospital suing you for payment. And if you wait long enough, you can lose your right to appeal the claim with the insurer.
These claims often present unique issues for executives, managers, and other professionals, whose families depend upon them for financial support and need to devote their attention to their business, rather than dealing with an insurer. We help clients obtain reimbursement for surgeries, procedures and treatments that should be covered under the health plan.