Apr 27, 2017

Mandated Insurance Benefits


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11/17/2008
Brian S. King
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Early in the evolution of the case law that defines ERISA, the Supreme Court ruled that insured ERISA plans must comply with state law requirements for mandated benefits. Metropolitan Life Ins. Co. v. Massachusetts, 471 U.S. 724 (1985) prevented Met Life from using ERISA’s preemption clause to ignore a mandated mental health benefit Massachusetts required all insurers doing business in that state to provide to its citizens.

Knowing about mandated benefits ensures that patients are in a better position to get their full measure of benefits from insured ERISA plans. For example, many states have mental health parity statutes. The statutes differ a great deal from state to state but many require insurers to provide mental health benefits at the same coverage levels as they provide for physical illnesses or injuries. If an insurer in such a state limits payment of inpatient mental health care to 10 days per year and provides a more generous coverage level for treatment of physical conditions, the mental health limitation is invalid and the patient can get the insurer’s denial based on the 10 day per year limitation overturned.

States have passed many different types of mandated benefits in the past two or three decades. For example, you can review a summary of Wisconsin’s mandated benefits here. The legislative decision to require insurers to provide certain benefits to their insureds is controversial because it raises the costs of insurance. But most people feel there should be a basic level of coverage that health insurers marketing comprehensive health insurance coverage simply must provide.



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