Is there any recourse for a denied STD insurance claim?

Business Contracts 2 views 1 answers
Someone I know had a heart attack a few years ago with no permanent heart damage. His health issues currently are around his breathing because he has been a heavy smoker for many years and under treatment by his doctor. Last year he went in for a heart cath and had a reaction to the anesthetic that was used. He was in intensive care and off work for several months afterward. His health insurance covered the illness but he was denied coverage for STD through his work because they said it was a pre-exisiting condition. No one could have known that he would have a reaction to the anesthetic. The doctor not only filled out the needed paperwork but also wrote a letter to the STD insurance company to no avail. He needs the money badly. Being off work that long really put him in debt.

Attorney Answer

1
Robert Kerr ·
Whether there is any recourse at this point is a question of the facts surrounding this scenario. The first thing I would want to know is whether this policy if governed by ERISA, which stands for the Employee Retirement Income Security Act of 1974. This federal law is usually applicable when a benefit, such as health, life, or disability insurance, is provided through an employer. If ERISA applies then certain steps must be followed to make sure that the administrative remedy process is exhausted. This administrative remedy is very, very important, and you will want to at least speak with someone in more depth about what this is and its significance. Once this administrative remedy process is complete this person would have the right to file suit in federal court. If ERISA is not applicable, typically the person would have the right to file a breach of contract action for the insurance company failing to pay the benefits that it agreed to pay. You would need to check the laws of the particular state that would apply to this contract for details on deadlines for filing suit, damages to be recovered, and procedures to follow in seeking recourse. Please be aware that if ERISA does apply there are some relatively short time frames that apply, and missing these deadlines can have catastrophic consequences. It is a very good idea to at least speak with someone about this STD claim.
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