ERISA Regulations in South Carolina
The Employee Retirement Income Security Act of 1974 (ERISA) regulates health and retirement plans offered by private employers and enables policyholders to collect wrongfully denied benefits. ERISA regulations apply nationwide, but many fail to exercise their rights because of their complexity.
At the Peace Law Firm, we focus on ERISA, allowing us to guide our clients through filing ERISA-covered claims. If your insurance company denies your claims, we can also assist with appealing denials as effectively and efficiently as possible. Because ERISA sets specific deadlines, contact us as soon as possible if you need help.
What Does ERISA Cover?
ERISA sets minimum standards and requirements for most retirement and health plans private employers offer their employees. It generally does not cover plans provided by government or church employers or plans offered solely to comply with other laws.Â
ERISA’s Requirements
Broadly, ERISA regulations:
- Require plans to provide information about features and funding;
- Set minimum participation, vesting, accrual, and funding standards;
- Establish fiduciary duties in those that control or manage plans;
- Require plans include benefit-related grievance and appeals procedures; and
- Grant the right to sue to recover benefits and for breach of fiduciary duty.
A fiduciary is a person or entity with a legal duty to act in your best interests, especially when handling money.
Retirement Plans
ERISA covers defined benefit and defined contribution plans.
Defined benefit plans, also called pension plans, guarantee specific monthly payments when a person retires. If a company terminates a defined benefit plan, participants are guaranteed payment through the Pension Benefit Guaranty Corporation (PBGC).
Employers and employees can contribute to defined contribution plans, like 401(k)s, where contributions are typically invested.
Health Plans
ERISA applies to employer-sponsored health plans, also called welfare plans, like:
- Group health insurance,
- Group vision insurance,
- Group life insurance, and
- Disability insurance.
It also covers several alternative health programs.
Participant and Beneficiary Rights
Participants in employer-sponsored plans are entitled to several rights under ERISA, including the right to:
- A plain-language explanation of plan coverage,
- Timely and fair claim processing,
- Temporary continuation of health insurance after coverage loss, and
- Recovery of benefits promised under the plan.
Plan administrators must provide plan information through a summary plan description (SPD) that describes:
- How the plan operates,Â
- What it provides, andÂ
- How to file a claim for benefits.Â
Administrators must also provide a Summary of Benefits and Coverage (SBC) explaining the important aspects of plan coverage.
Fiduciary Requirements
ERISA establishes requirements for plan fiduciaries, including obligations to:
- Act responsibly with funds,
- Diversify investments, and
- Not benefit others in exclusion of beneficiaries.
If a fiduciary fails to meet these requirements, you may recover damages.
How Can You Enforce Your Rights Under ERISA?
The Employee Benefits Security Administration (EBSA), part of the U.S. Department of Labor, enforces ERISA. While EBSA prosecutes violations, ERISA enforcement typically begins with an individual filing a claim using procedures established in the relevant plan.
Plan Information
You can request plan information from your employer or administrator. If they fail to provide the information, you can request assistance from EBSA.
Timeliness
Generally, plans must respond to health claims within:
- Urgent care claims: 72 hours,
- Pre-service claims: 15 days,Â
- Post-service claims: 30 days, and
- Disability claims: 45 days.
Failure to meet these deadlines can give rise to ERISA claims.
Fairness and Recovery of Promised Benefits
Violations involving questions about the fairness of claim processing and whether you are entitled to certain benefits can be more complex.
If a plan denies your claim, you may appeal using the plan’s procedures. Someone at the company reviews the decision and determines whether to uphold or reverse it based on the available record and any evidence you provide.
If the company denies the appeal, you may bring your claim to a federal court. When you do, you rely on the evidence presented during the internal review, so it is vital to take that stage seriously.
Continuation of Health Benefits
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), which amended ERISA, employers must provide you notice of your right to continue to receive health benefits for a time after losing your coverage. You can request EBSA’s help if you do not receive notice.
Fiduciary Violations
A fiduciary can breach their duties by failing to follow their responsibilities. For example, they may:
- Make a financially irresponsible investment,
- Embezzle funds,
- Fail to diversify, or
- Benefit themself over beneficiaries.
Participants can sue to recover damages following a breach of fiduciary duty.
South Carolina and ERISA
As a federal law, ERISA applies in South Carolina. South Carolina also has ERISA-related provisions:
- Excluding certain ERISA-covered plans from extra requirements,
- Authorizing membership in the South Carolina Public Employee Benefit Authority based on experience with ERISA claims, and
- Requiring certain state programs to comply with ERISA.
Primarily, when South Carolina law mentions ERISA, it ensures that state law complies with federal law.
Speak with an ERISA Attorney
Navigating ERISA claims is challenging, but ERISA can allow you to collect hundreds or thousands of dollars you are entitled to. If you need help with an ERISA-related claim in South Carolina, contact the Peace Law Firm as soon as possible.
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