Case Study: ERISA at Work
The Employee Retirement Income Security Act of 1974, known by its acronym, “ERISA,” is a federal law that sets standards for the protection of individuals covered under most voluntarily established private industry retirement and health plans. It contains a very specific set of rules that apply in the event an employee’s claim is denied. Fairness to employees is an important aspect of this act, and its rules are something that PartnerSource helps employers follow every day.
Recently, a worker who was complaining of lower back pain was denied his claim based on a medical judgement that his lower back pain was not related to an on-the-job injury. The employee exercised his right to request an appeal of the decision. In the context of administering the appeal, the fiduciary read carefully his appeal letter and noted the employee’s complaint was that the physician he had seen was not an orthopedic specialist. Understanding his concern and recognizing the employee’s right to a full and fair review, the fiduciary offered him a consultation from a board-certified orthopedic surgeon.
After visiting with a specialist who took the time to explain his personal medical condition, the employee withdrew his appeal. He better understood his condition and went back to work with new knowledge.
“These rules are in place for a reason,” noted Staci Cassidy, J.D., senior vice president with PartnerSource. "ERISA requires a process that encourages communication between the plan and its participant. This employee had a valid complaint and did not understand. He just needed to be seen by a knowledgeable specialist who could explain to him what was really happening with his back. The level of communication required by ERISA, together with an employer willing to take the time to explain how a personal medical condition has coverage too, will create results that make sense."