Delayed and Denied: Toward an Effective ERISA Remedy for Improper Processing of Healthcare Claims
34 Pages Posted: 30 Mar 2013
Date Written: June 1, 2010
This article advocates a shift in thinking in the enforcement of claims processing regulations. Under the current approach, most non-compliance is excused under the “substantial compliance” doctrine, and even substantial departures from the claims regulations generally result in no substantive remedy. This approach excuses practically all instances of regulatory non-compliance and places the enforcement burden on those least able to shoulder it — the individuals seeking and paying for medical care. Instead, ERISA’s goal of ensuring contracted benefits would be better served if enforcement moved to a presumed-harm approach, akin to the approach used in numerous consumer finance laws. This article argues that the same concerns driving consumer financial protections have even greater force where healthcare is concerned.
Keywords: ERISA, Healthcare, Claims, Denial, Remedy
Suggested Citation: Suggested Citation