What ERISA Does Not Cover
The most important thing to understand about what ERISA does not cover is a legal remedy for damages resulting from injury, suffering, or death, under a managed-care plan. You may be able to sue an ERISA-governed plan to get coverage, a certain test or procedure, but you cannot sue for damages that occur if there was a delay in getting care - even if this results in injury, economic loss, or death.
ERISA-governed managed care plans protect the plan, not the consumer, unless there is a fiduciary breach, in which case, ERISA law may help consumers. But even then, you cannot be awarded damages.
For example, let’s say that a managed care plan denies you timely referral to another doctor, or will not approve necessary tests or procedures. As a result of the delay you suffer health problems, or even death. You cannot sue the plan to get damages for any injury, suffering, or loss of life that result.
These severe limitations in the ability to sue apply to ERISA health, life, and disability plans.
ERISA laws also do not apply to plans outside the U.S., or to private insurance plans purchased by individuals.
Can Individuals Sue an ERISA-Governed Managed Care Plan?
ERISA laws make it tough to sue managed care, however, several precedent setting cases have been argued successfully, including one in the U.S. Supreme Court. Since ERISA laws, and suing manage cared is a very complex issue, with each case needs to be evaluated individually. If you have trouble with an ERISA governed managed care provider, it is best to consult an attorney who specializes in insurance law.
The following resources offer more information about specific ERISA case law:
- ”Can I Sue My HMO? (What is ERISA?)”. This article was written by Jeffrey I. Ehrlich, the first attorney to successfully win an ERISA case in the U.S. Supreme Court. The decision established which laws apply to ERISA cases.
- Ballard Spahr Andrews & Ingersoll, LLP. This site lists some of the cases that have come before various courts challenging ERISA law.
