CalPERS or the State of California's Public Employees Retirement System provides retirement benefits to numerous state and local government employees. The California State Teachers' Retirement System or CalSTRS provides retirement, disability and survivor benefits for full-time and part-time California public school educators. Many other government pension programs exist that are largely built upon the same foundational principles and incorporate the same body of law.
ERISA, the Employee Retirement Income Security Act, is a Federal law which governs many employee welfare benefit plans including pensions, health insurance, and disability policies. Those plans which are not covered by ERISA are typically individual policies or policies issued to employees of governmental entities. If a benefit plan is not covered by ERISA, a beneficiary can sue the plan for bad faith insurance practices and other state law causes of action. If, however, you work for a private employer and you receive benefits through a group policy, your plan is likely subject to ERISA.
In the event that an ERISA beneficiary is denied pension benefits, coverage for medical expenses, or disability benefits under a plan governed by ERISA, the beneficiary can only sue the plan after exhausting any available administrative remedies. This means the beneficiary must submit internal appeals of any denial of benefits with the Plan Administrator as required by the Plan's documents and await a final decision before suing in Court. This also means the beneficiary can only sue in Federal Court and cannot allege state law causes of action against the plan, nor obtain bad faith damages, emotional distress damages, nor punitive damages. In an action for denial of benefits from an ERISA plan, the beneficiary can only obtain the benefits owed and attorneys fees. The evidence in an ERISA case in Federal Court will often be limited to the beneficiary's claims file which has been maintained by the insurer or Plan Administrator.
ERISA Administrative Appeals: A Key Step in the Process
Because ERISA severely restricts the type of damages a beneficiary can obtain in litigation, it is wise for a beneficiary to treat internal appeals with the Plan seriously. A beneficiary should submit all supporting documentation and all supporting legal arguments to the Plan during the administrative appeals process in order to create the best record possible in the event that litigation is necessary. Our law offices have a breadth of experience in filing administrative appeals in cases where health insurance companies have denied coverage for certain medical expenses and where insurers have denied short-term or long-term disability benefits to their insureds. Attorneys at MARTIN & VANEGAS, APC gather and review medical records, obtain assessments and reports from treating physicians and psychiatrists, and author persuasive appeals citing relevant federal case law.