Insurance Claims AttorneyA former player for the National Hockey League’s (NHL) Dallas Stars recently had his disability claim lawsuit thrown out by a Texas federal court.  Aaron Rome, a defense man who played for the Stars from 2012-2014, filed the lawsuit in relation to a career-ending hip injury he suffered in a 2014 game against the St. Louis Blues.

In the suit, Rome claimed that HCC Life Insurance Company mishandled his disability claim. He also alleged that the company, nor the NHL, responded to inquiries about his coverage, and did not provide the documents he requested related to the denial of his initial claim.

Judge Rules Rome Did Not Follow Procedure 

The judge determined that Rome had not exhausted his administrative remedies before filing a lawsuit, and stated that in cases involving ERISA (a federal law), state law is pre-empted by federal jurisdiction.  Although the lawsuit was thrown out, the judge advised Rome that he could still pursue his claim under the Employment Retirement Income Securities Act (ERISA) against a “proper ERISA defendant.”

Rome was given 30 days to properly file a claim under ERISA before the judge would dismiss the lawsuit with prejudice. 

What Is ERISA?

ERISA is a federal law that establishes minimum standards for retirement, health, and welfare benefits plans, including life insurance, disability insurance, and apprenticeship plans.  It is specifically designed to protect retirement benefits, and is administered by the US Department of Labor.

ERISA applies to benefits plans offered by private companies only.  Offering these benefits plans to employees is elective for private businesses, but many companies offer insurance plans as an incentive to attract and retain high-quality talent.  In Rome’s case, his plan with HCC Life Insurance Co. was provided to him as an employee benefit when he joined the NHL.

ERISA plans are subject to a variety of federal regulations and compliance standards, including managed care and fiduciary conduct, reporting and accountability, disclosures to plan participants, procedural safeguards, and financial and best interests protections.

What Benefits Plans are Subject to ERISA

Benefits plans that fall under ERISA jurisdiction include:

  • Medical, surgical, or hospital care benefits
  • Sickness, accident, disability, unemployment, or death benefits
  • Vacation benefits
  • Apprenticeship and training benefits
  • Daycare centers
  • Scholarship funds
  • Legal services benefits
  • Holiday benefits
  • Severance benefits
  • Housing assistance benefits

Some important exemptions to ERISA include:

  • Government, church, or statutory exempt plans
  • “Payroll Practice” exemptions
  • Voluntary plans exemptions

If you are unsure whether your employee welfare benefits plan is ERISA-governed, ask your employer or HR representative.

Confronting the Insurance Claims Process 

Many employees around the country rely on the health and welfare insurance plans provided by their employers.  Employers negotiate these plans with massive insurance companies on behalf of its employees. Individual insurance claims are evaluated and approved by the insurance companies themselves.

Unfortunately, the process by which claims are approved is often confusing, and insurance companies often seemingly arbitrarily reject a claim on an unfair basis.  Employees who have sustained injuries or are waiting on life-saving medical treatment are frequently left in a confusing purgatory as they attempt to contest an insurance claim rejection.

If Your Claim Has Been Denied, You Need Legal Representation

For complex insurance claims, an experienced insurance claim attorney will know how to navigate through the frustrating bureaucracy of the insurance company.  At David K. Wilson & Associates, our team will help you get the benefits you are entitled to under your plan.  Contact our office today for a free consultation at (903) 870-9050.