Disability Insurance Blog

What types of claims are there for ERISA purposes?

disability insurance

Friday, November 3rd, 2017

Workers in New York who cannot work due to a short-term or long-term disability may be in need of financial assistance. This can come in the form of benefits from a disability insurance policy. The Employee Retirement Income Security Act (ERISA) sets rules regarding how an application for disability benefits under a disability insurance policy is processed, how long an insurer has to decide on an application and what the worker’s rights are should their application for benefits be denied by their insurer. For ERISA purposes, there are a number of different types of claims that a person can pursue.

First, there are group health claims. One type of group health claim are pre-service claims. These are those in which a policyholder must receive medical care before the insurer will provide benefits. For example, the policyholder may need to have their care preauthorized, or there may need to be a determination with regards to what type of medical care is needed before benefits can be provided.

A specific type of pre-service claim is an urgent care claim. Such a claim will receive quicker approval than other kinds of claims if the person’s health will be compromised should the insurer wait to approve the claim in the amount of time it would usually take with regards to pre-service claims. For example, the policyholder’s doctor can let the insurer know that there is an emergency. If so, the insurer will process the claim as an urgent care claim.

A third type of group health claim is a post-service claims. These are those that are submitted after a policyholder receives medical care. They are meant to reimburse the policyholder for their medical expenses.

In addition to group health claims, there are disability claims. These types of claims are those in which the insurer must determine whether or not the policyholder is disabled in order to approve the policyholder’s application for benefits.

An insurer has a certain time period in which it must decide on a policyholder’s application for benefits. This time period is dependent on what kind of claim it is. Workers pursuing health or disability benefits may want to seek legal advice first, to ensure they are treated fairly.