A major group health insurer denied all of the health insurance claims of the employees of a company that had purchased a large group health insurance policy. The employees were all clearly covered under the group policy. The reason for the claim denials, according to the health insurer, was that the group insurance policy had lapsed for non-payment of premium. After many rounds of letters and argument between the clients’ prior lawyers and the insurer, the employer turned to our firm for help.
We determined that the group plan was governed by ERISA. We designed an approach that was vastly different from the efforts of the prior counsel. Using ERISA’s tools that allow us to investigate a health insurer without filing a lawsuit, we were able to obtain a quick victory.
The investigation we conducted demonstrated that the insurer was incorrect in its position and it agreed to deem the group policy in full force and effect for the entire disputed time period. All of the employees’claims were then re-processed and paid.