Fill and Sign the Erisa Collection Sample Complaint Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF )       ) ) V. ) NO.       ) ) NAME OF DEFENDANT )       ) ) COMPLAINT 1. The plaintiff is__________, an adult resident citizen of __________ County, __________. 2. The defendant is: __________. This defendant may be served with process at __________, __________, __ __________. 3. This suit is brought under (Employee Retirement Income Security Act of 1974) to recover health care benefits, under an employer sponsored insurance plan. On __ __________ _____, plaintiff began employment with __________ a participating employer in the __________ Employee Health Plan (the Plan). Also, on that date, plaintiff became a covered beneficiary of the Plan. At the time of hire, and as an inducement to come to work for __________, plaintiff was advised by the personal manage of __________, that she would be fully covered for medical loss under the Plan. Plaintiff was at no time provided a summary plan description of the Plan, as is required by ERISA. The plant manager and personnel manager of __________ were fully advised by plaintiff that she suffered from a condition known as super ventricular tacacardia and asmasa. 4. In reliance on the representations made to plaintiff by the plant manager and personnel manager of __________, plaintiff quit her job and gave up her coverage under her existing health care plan, and plaintiff began work with __________ on __ __________ _____. On __ __________ _____, plaintiff began to experience problems with her heart. Plaintiff received treatment, surgery and incurred medical, hospital and drug bills, through __________ _____, totaling $______._____. 5. On __________ __, __________ __ and __________ __, _____, plaintiff received letters from the Plan Administrator, advising her that her medical and hospital were denied by the Plan, based on a claim of pre - existing condition. The bases of denial by the Plan Administrator are totally incorrect, insofar as plaintiff was never provided with a copy of the Summary Plan Description, and in fact because plaintiff relied on the advice and inducements of the plant manager and personnel manager, who in fact were acting as agents of the Plan, and they were acting as Plan fiduciaries, by giving plaintiff critical information about the Plan and her coverage. 6. Plaintiff brings this action to obtain a declaratory judgment, to determine that she is covered under the Plan, and to determine that the Plan may not rely on any Pre - Existing Conditions Limitation to deny her claims, and to determine that the Plan is liable to pay her medical, hospital and drug bills as referenced above. Respectfully submitted, __________ _____________________