Resources appeal checklist

ERISA mandates that before a beneficiary files a lawsuit after her claim has been denied, she should exhaust all administrative remedies – submit an internal appeal. In other words, if your life insurance claim is controlled by ERISA and it has been denied, you can only file a lawsuit after your administrative appeal is denied.

The denial letter which the insurer sends to the beneficiary usually sets out a procedure for filing an ERISA appeal – it provides the appeals unit address, ERISA deadlines and the information on the independent review examiner who will conduct the review. It is in your best interests to have the assistance of a competent, experienced ERISA attorney when you file an appeal and many attorneys will take your case on a contingent fee basis – it means you will not need to pay your attorney unless you recover the proceeds. However if you decide to file an appeal on your own, keep in mind the following tips:

Things to Remember If You Decide to File an ERISA Appeal Yourself

  • As a beneficiary to a denied ERISA claim, you are entitled to only one appeal;
  • The deadline to file an ERISA appeal is usually 60 days from the date you receive the denial letter;
  • Failure to appeal before the given deadline means you waive your right to pursue the claim any further;
  • If you call the insurance company and state that you “want to appeal the denial of benefits,” the insurer may treat your statement as an appeal and will start a review process immediately. If you later file a formal appeal, it will not be accepted. Make sure that you clearly state that you intend to file an appeal in the near future and now want to get the life insurance policy and other relevant records in order to prepare for the appeal;
  • Do not file an appeal without submitting new evidence – documentation, legal briefs, medical opinions, research reports, expert reports, etc.;
  • Every piece of information you plan to include in a lawsuit must be part of the record during the appeal;
  • Any information you omit may never be heard or considered by a court.
  • Request the complete file on the insured from the insurance company before initiating an appeal. The file may include the life insurance policy, doctor’s notes, medical records, videos, expert opinions, internal call/email log, videos and recorded phone conversations;
  • Request additional statements from doctors if the claim denial is based on health history of the insured;
  • Research relevant ERISA provisions and cite them in your appeal;
  • Request written affidavits from your friends and family members if they are familiar with the insured’s health/condition/circumstances and can support your position;
  • Review of an appeal usually takes 60 days and the insurer will notify you in writing if there is a delay. In rare cases where the appeal review is conducted by a committee or board of trustees which meets at least quarterly, making a decision on your appeal can take up to 120 days;
  • Once the final decision has been made, you will be told the reason and the plan rules upon which the decision was based;
  • If your appeal is denied, you cannot file another administrative appeal with the help of an attorney.

If you have any questions about how to file and what to include in your individual appeal, consult legal counsel.