Understanding the ERISA Appeal Process: What Beneficiaries Need to Know About Denied Claims to Win

Many group life insurance plans maintained in the United States are ERISA plans. ERISA plans are employer-sponsored plans that usually deduct premium payments from the employees or make contributions by the employer. ERISA does not apply to welfare group plans established or maintained by government organizations or religious institutions. In spite of the fact that ERISA offers many protections to plan participants, many claimants are denied their benefits.

ERISA laws are very complex and can be very case-specific. A person who just lost a loved one may have a hard time navigating an ERISA life insurance claim denial without legal help. If your ERISA claim has been denied, be aware of a time frame within which you are expected to file a 

comprehensive legal brief. The administrative appeal is the first mandatory step in fighting an ERISA claim denial and you should consider consulting a lawyer. In this article, our ERISA attorneys have prepared a guide to help you better understand how ERISA works, what rights plan beneficiaries have and how to fight a claim denial. If you, or someone you know has issues with a denied ERISA claim, call us at (888) 510-2212 for a free consultation.

ERISA Appeal Process

An ERISA appeal is the procedure you must follow if your claim for benefits was denied under ERISA law.

In most ERISA cases, you need to submit an administrative appeal before filing a lawsuit against the insurance company or the employer. Otherwise, if you decide to sue your insurance company without first exhausting administrative remedies, your court action may be barred.

To maximize your chances of recovering the full and fair benefits you are owed, you need to consult with a lawyer that has experience with ERISA cases and can file the appeal on your behalf.  Our life insurance lawyers can help you recover your wrongfully denied claim fast, no matter the reason invoked by the insurer.

erisa appeal

How to File an Appeal Successfully

The denial letter that 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.

However if you decide to file an appeal on your own, keep in mind the following tips:

  • 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 or 180 days from the date you receive the denial letter.  It means that a beneficiary whose claim has been wrongfully denied has only 60 (or 180) days to investigate the denial, draft an appeal, prepare supporting documents, draft the appeal and file it;
  • 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;
  • 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.
  • 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 a lawyer.

Your appeal should include:

  • New evidence – documentation, legal briefs, medical opinions, research reports, expert reports, etc.;
  • 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;
  • Relevant ERISA provisions;
  • Additional statements from doctors if the claim denial is based on health history of the insured;
  • Written affidavits from your friends and family members if they are familiar with the insured’s health/condition/circumstances and can support your position.

Unfortunately, even if with these precautions, an appeal prepared without a legal brief is rarely winning. ERISA laws are very complex and require a thorough investigation. Consider consulting legal counsel. Life insurance lawyers at our law firm have the experience you need to help you recover your ERISA benefits.

erisa appeals regulations

What if Your Appeal Was Denied: ERISA Lawsuits

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. Read more about how to deal with ERISA litigations.

If you consider filing a lawsuit to review a denied claim under ERISA, our law firm can help. We have successfully reversed many denied life insurance claims and can help you recover your wrongfully denied benefits fast.

Our ERISA Attorneys Can Help Win Denied Claims and Appeals

At Kadetskaya Law Firm, we have a high success rate of recovering the benefits our clients were rightfully entitled to. 

Our ERISA employee benefits attorneys work on a contingent fee basis – it means you will not need to pay unless you recover the life insurance death benefits. Only then will we charge a reasonable legal fee. We take pride in offering competitive contingent fee structures and will work with you to ensure you are comfortable with the fee. 

If you or someone you know has issues with a denied ERISA claim, call us at (888) 510-2212 for a free consultation. We have the experience you need to win your case. 

Here are a few cases successfully handled by our ERISA lawyers:

by Tatiana Kadetskaya

by Tatiana Kadetskaya

Attorney Tatiana Kadetskaya has over 10 years of experience in life insurance law representing beneficiaries and policy owners. She is best known for successfully collecting denied and delayed claims and settling complex beneficiary disputes and interpleader lawsuits.

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