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Other Employee Benefits

Employee Benefits

Employers will often provide to their employees a multitude of benefits including, among others, short term and long term disability insurance, health insurance, life and accidental death and dismemberment insurance, and long term care insurance. If the employer is a private entity and the benefit is offered as a group benefit, chances are the law of ERISA will apply to all claims made for these benefits. The acronym ERISA stands for Employee Retirement Income Security Act. Even though the acronym references only retirement income, it also applies to those other, group, employee benefits . ERISA is a complex, federal law consisting of the statute, regulations and court decisions. In addition, cases involving ERISA in the United States District Court for the District of Maine must unfold according to the procedure laid out in the unique ERISA Scheduling Order. Attorney Nadeau has experience in ERISA matters and will personally guide you through the entirety of your benefits case.

Health Insurance

If your health insurance coverage is provided by your employer, chances are, with few exceptions, it will be governed by ERISA. A health insurance policy governed by ERISA will be subject to all of the complexities of the federal statute, regulations and court opinions as to all aspects of the coverage. It establishes the type and detail of information to which you are entitled such as who is eligible for coverage, how benefits are determined, what benefits are covered,  and how they are paid. ERISA also establishes the process for challenging an adverse decision and conditions for filing suit for benefits. Your health insurance benefits could be  affected by the Consolidated Omnibus Budget Reconciliation Act (COBRA) which means you may be entitled to continue the health insurance coverage provided by the employer even though, for instance, you no  longer work at  your job or your spouse,  through whom you had the coverage,  has died.

ERISA requirements can be unforgiving. You must adhere to the schedule for filing a claim and appealing denials. You must muster and organize your medical facts to present the best possible claim which  is time-consuming and frustrating. Don’t hesitate to contact Attorney Nadeau immediately if you feel you may have a health insurance coverage issue.

Pension and Retirement Plans

As with other employee benefits, your employer is not required to provide a pension or retirement plan.   If your employer does, however, ERISA provides guidelines on all aspects of the plan.  It governs whether you are eligible to participate in the plan and, if so, when you can start to participate, how the funds in the plan are managed and when you have a right to collect accumulated amounts. These benefits take the form of either Defined Benefit Plan or Defined Contribution Plan.  The Defined  Benefit Plan is funded by your employer and provides a specific, monthly  amount at retirement based upon a formula which includes factors such as your salary, years of employment and age at retirement.  A Defined Contribution Plan is much more common.  The contributions to these plans can be made by the employer or employee as deferred wages or both.

In every pension and retirement plan there are individuals who manage the plan using their discretion.  These people are called fiduciaries.  You have a right to sue your plan and fiduciary to, among other things,  appeal a denied claim for benefits;  clarify your right to future benefits;  and request plan documents which you requested but did not receive.  Contact Attorney Nadeau at the first sign of some anomaly or concern you might have about your pension or retirement benefits.  As with all cases governed by ERISA the claims are complex and the deadlines are draconian.

Life Insurance/Accidental Death and Dismemberment

If your life insurance benefit is provided by the employer of the deceased, most likely ERISA will apply. The insurer will press all defenses available. First, it will analyze all aspects of the application looking for any failure to disclose even the most negligible and irrelevant bit of information. In particular, it will look for what it may characterize as misrepresentation and possible pre-existing conditions. It will scrutinize the facts surrounding the death to find an exclusion, that is, death caused by one or more of the factors which can be used to deny coverage such as death arising out of the use of alcohol or drugs or suicide. You may also have to contend with procedural-type defenses such as death which occurred after the nonpayment of a premium or death that occurred before the coverage was initiated or after it was terminated according to the terms of the policy.

Accidental Death and Dismemberment is coverage that pays in addition to the life insurance benefit when the death is accidental. In addition, this coverage pays benefits even when the insured doesn’t die but loses a limb or sight. Accidental Death and Dismemberment coverage can be included as part of the employer’s group life insurance benefit or can be offered as a separate, elective benefit.

As in all ERISA-based claims, the procedures and standards regarding proof for both Life Insurance and Accidental Death and Dismemberment insurance are stringent. You should contact Attorney Nadeau at the first sign of a potential problem.

Long Term Care Insurance

Long term care insurance is different from health insurance. Health insurance provides coverage for medical costs resulting from health issues of all types. Persons eligible for long term care  coverage are usually defined as persons who are unable to perform a number of activities of daily living. This means everyday routines involved in personal care which persons normally do on their own such as bathing or showering, brushing teeth, combing hair, dressing, toileting; doing laundry; cooking, and eating. Thus, unlike what is commonly thought, age is not the factor that determines whether long term care coverage is warranted. If your long term care insurance is a benefit provided by your employer, ERISA, with all of its procedural and other hurdles, could apply to your claim. Even if ERISA does not apply, a claim for long term care benefits can be complicated. You will have to apply all of the definitions in a policy to discern what is covered,  for instance, the definitions of facility, nursing care, personal care services, and activities of daily living and determine how these are interrelated. You will have to confirm that you are eligible, that is, that you have filed a claim in a timely manner and have provided all of the medical and other evidence. You will have to carefully prepare your claim so as to avoid the pitfalls of limitations and exclusions. Collecting on a long term care claim can be particularly difficult. Attorney Nadeau can help you every step of the way.

WAIVER OF PREMIUM FOR DISABILITY

When you become disabled and so unable to work, you will likely be in extreme financial distress.  Luckily, you may not have to lose insurance coverage that you need because you are unable to pay premiums. Many health, life, and disability insurance policies contain provisions that you will not have to pay premiums while you are disabled.  This means, however, that you will have to prove that you are disabled according to the terms of the policy.  Attorney Nadeau will do what it takes to prove your disability, thereby preserving your coverage.