The Employee Retirement Income Security Act (ERISA) is a federal law which governs benefit plans sponsored by employers. Thus, ERISA governs the rights and duties of employers, insurers, and claimants, and sets forth standards of conduct for those with discretionary authority over the plan, known as fiduciaries. ERISA dictates most claims for employer-sponsored benefits, including claims under pension, disability, life and health insurance plans, as well as some severance pay plans. Claims for benefits based on an individual policy, or provided through a governmental agency (including governmental employers) are not governed by ERISA.
The Department of Labor has issued an extensive set of benefit claims regulations which must be followed by plan administrators. Before a claimant can sue for benefits in Court, the claimant must generally follow the claims review process established by the plan administrator, in according with the regulations. If the plan administrator follows the regulations, then if the claimant files a lawsuit, the plan administrator's decision will only be overturned if it is "arbitrary and capricious" -- a quite high standard. Generally, the claimant is also bound to the administrative record; i.e., he or she cannot present new evidence regarding the merits of the claim in Court. Conversely, the plan administrator may lose the benefit of this deferential review if its fails to substantially comply with the regulations. As a result, it is generally a good idea for a claimant to seek the advice of counsel experienced in ERISA before all of his or her internal appeals have been exhausted. Similarly, employers, especially those who are self-insured, should ensure that those conducting plan administration on its behalf have complied with the regulations.
We have a long history of representing claimants, employers and employer-sponsored plans in ERISA claims litigation, and in the presentation of claims during the prior administrative processes, as well as in the prosecution and defense of non-ERISA claims. We have been involved in dozens of claims disputes, from the filing initial claims, through litigation. We also have litigated claims of breach of fiduciary duty under ERISA, and bad faith claims under Pennsylvania law.
Mr. Salmanson is a nationally-known speaker on the litigation of ERISA claims, having presented at legal conferences throughout the country.
Sampling of Cases
In 2011, we were successful in securing benefits for Robert Miller, a former American Airlines pilot who had been cut off from the disability payments he had been receiving for several years. After several years of litigation, the Third Circuit Court of Appeals, in a broad, widely-reported precedential opinion, ordered American to retroactively reinstate Mr. Miller's benefits. The opinion was noteworthy in many respects, and has been widely cited by other courts throughout the country.
Just a few months earlier, we won another victory in the Third Circuit, which held that our client had wrongly been denied participation in an enhanced disability plan provided by his employer. The issue in that case was whether the claimant, who had just returned from a short disability leave, was "Actively at Work" within the meaning of the policy.
In another precedent-setting case from the Third Circuit, we obtained a judgment against Fortis Insurance Company based on our clients' claim that Fortis had wrongfully denied life-saving chemotherapy treatment to a young girl suffering from leukemia. The Court held that the girl's treatment for a fever prior to the effective date of the policy, did not trigger a "pre-existing" exclusion provision of her health insurance policy, even if the fever had, in fact, been a symptom of the leukemia.
Our cases have involved a wide variety of medical conditions, from pediatric cancers and rare heart conditions to more routine surgical interventions. These claims have involved the meaning of such terms as "preexisting conditions"; "experimental" or "investigational" treatments; coordination of benefits issues; emergency out-of network and other "medical necessity" issues; and participation and other qualification issues. We have represented not only individual claimants, but leading health care providers in the Philadelphia area in regard to insurer's refusals to pay for medical claims.
" After we began speaking, you gave me a quiet, implied sense of hope and confidence I hadnít had in a couple of years. The expeditious manner in which you were able to turn this travesty into a win for me is still an amazement Ė I will forever be in your debt and canít thank you enough. Please accept my heartfelt gratitude for giving me a new lease on life."
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