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Frequent Inquiries about the Firm

Disclaimer: These questions and answers are not intended to provide legal advice but to provide general information about ERISA and this office’s services.

Yes. We provide free consultations by phone and our goal is to determine whether we can represent you regarding your legal issue and if not, to give you some information to help you find someone who can assist you or to empower you to handle the matter yourself.

ERISA is a federal law which governs benefits which are provided by employers. Benefits may include medical, disability, life insurance, pension, and more. ERISA is an acronym of the Employee Retirement Income Security Act of 1974. ERISA requires employer plans to follow specific procedures regarding the appeal process and the participants’ right to file a lawsuit for benefits.

ERISA has two main exceptions: it does not govern plans established by government or religious employers.  

No, we do not handle cases involving these government provided health benefits. These programs follow very specific rules and different laws than ERISA which do not provide for attorney’s fees or costs which make it very difficult for attorneys to handle these types of cases. There are nonprofit organizations such as legal aid which may offer assistance.

Please see the Additional Resources at the bottom of this page.

Yes. Please reach out if you would like to refer a potential client. We are also happy to refer potential clients to attorneys in other practice areas.

Yes. While we are based in California, our practice is nationwide and we have experience litigating cases in Washington, Nevada, Arizona, Montana, Kansas, Texas, Illinois, Georgia, North Carolina, New Jersey, New York, and Connecticut. If a lawsuit is required, we work with attorney colleagues in other states who serve as local counsel on the cases and we remain lead trial counsel. 

Cases filed in federal court usually resolve through settlement and sometimes trial. In an ERISA case, trial largely consists of briefs filed by each side and an oral argument to the judge, if permitted by the judge. Generally, ERISA cases reach trial within one year of filing the complaint. 

We work on a contingency basis, meaning that our fee is contingent on recovering your health benefits. We receive a percentage of the health benefits that are paid as a result of our work in appeal or litigation. 

Frequent Inquiries about Appeals

Disclaimer: These questions and answers are not intended to provide legal advice but to provide general information about ERISA and this office’s services.

It depends. If your health claim was denied, you should send an appeal which you can do on your own and we have resources to give guidance on how to appeal. Some clients prefer to handle the appeal themselves or have already done the appeal before contacting our office. Some clients prefer to have an attorney handle the appeals. When we represent clients during the appeal process, our goals are to get the claim paid first and also to fully prepare the case for litigation, if needed.

If your health benefits were denied, you can appeal to ask the claims administrator to change its mind and approve the benefits. While you don’t have to appeal, the denial will not get overturned without action. Also, completion of the appeal process is necessary to be able to file a lawsuit in court. 

If your ERISA health benefits were denied, you can request an appeal in writing or over the phone. An appeal in writing is preferable because your appeal will be received and included in the claim file. An appeal by telephone may not be documented correctly because you have no assurance what the person you are talking to is documenting at their end.

Under ERISA, participants have 180 days from the date they received their denial, to submit an appeal. An ERISA plan cannot require more than two levels of appeal. A second level appeal could be due in as soon as 60 days from the first level appeal denial. 

A health appeal should include letters of support from any medical or mental health providers who are advocating for the patient to receive the requested healthcare. The appeal should include medical records, treatment records, medical studies, or other documents which refute the basis for denial. The appeal should be in writing and explain why the denial was wrong.

ERISA health plans are typically funded one of two ways: (1) insured with an insurance policy or (2) self-funded with the general assets or trust of the employer. If a plan is insured, it is required to comply with the insurance laws of the state in which the insurance policy was issued. A self-funded plan is not insured and therefore is not required to comply with insurance laws. However, regardless of funding, any ERISA health plan is required to comply with ERISA regulations. An ERISA health plan may hire a separate claims administrator to handle the claims and appeals. A separate claims administrator may be hired for mental health claims and appeals as well.

ERISA plans are required to provide plan documents (may also be referred to as an SPD or Summary Plan Description) within 30 days of the participant’s written request to the Plan Administrator. Plans may be liable for a penalty of $110 per day for each day that the plan documents were not provided. 

No, highly unlikely. ERISA streamlines the litigation process and courts generally disallow evidence (like a client’s deposition) that was not developed during the appeal process. 

No. You are not obligated to attend court proceedings in an ERISA case unless some unique circumstance requires your presence. Clients are required to participate in a settlement process such as mediation or settlement conference. These settlement processes are usually by video conference, i.e. Zoom.

Mental health parity laws provide protections for mental health patients to ensure that they will receive mental health coverage that is on par or equivalent to the health coverage provided to patients who are receiving healthcare services for physical health conditions (not mental health). An example of a plan provision that does not satisfy mental health parity is a plan that provides only 10 days of residential treatment (for mental illnesses) but provides 100 days of skilled nursing treatment (for physical illnesses). Residential treatment is generally considered on par with skilled nursing care.

Please note that our office does not provide consultation or representation regarding Medicare, Medi-Cal, or Medicaid benefit issues. There are nonprofit legal aid organizations which may be able to assist you with these matters, such as:

Center for Medicare Advocacy

Center for Health Care Rights

California specific:

Neighborhood Legal Services of LA County

Community Legal Aid SoCal

Bay Area Legal Aid

Legal Services of Northern California 

Additional Resources