ABA Family Legal Guide

Health-Care Law

Health-Care Options

Health Insurance and Managed Care Organizations

Do you have access to external review?

There are some health plans that do not have access to external review. Under the Employee Retirement Income Security Act of 1974 (ERISA), there are some kinds of self-insured employer-paid plans that are exempted from the state's external review procedures. In fact, nearly 70 percent of the health-care insurance currently in place in the United States is subject to ERISA. As a practical matter, this means that people who have disputes with their plans are limited to the internal grievance procedures and cannot sue in court for such things as breach of contract, breach of the implied covenant of good faith and fair dealing (bad faith), infliction of emotional distress, and fraud. As noted earlier, it also means that the plan may not have to comply with mandated coverage laws.

Consult your employer's human resources department to determine if your plan is self-insured. If it is, then you probably cannot use your state's external review process.