Delayed and Denied: Toward an Effective ERISA Remedy for Improper Processing of Healthcare Claims

Abstract

The healthcare reform effort culminating in the Patient Protection and Affordable Care Act (PPACA) has focused, to date, on the plight of the uninsured and on barriers to insurance such as pre-existing condition exclusions. Reform efforts focus less often, however, on threats to healthcare benefits for people who do have health insurance. When insured individuals suffer a serious illness, does their insurance live up to its promise? One overlooked threat to the insured concerns administration of employer-sponsored health insurance plans. Specifically, participants' benefits are threatened by the lack of consequences when administrators of such plans improperly process claims for healthcare benefits by delaying the decision, failing to conduct a complete review, or simply denying the claim incorrectly.