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ERISA claim denied · Benefit claim lawyersA plan said no. That is not the last word.

When a disability, pension, health, life or severance plan through work denies your claim, federal law generally gives you a written explanation, free copies of your claim file on request, and a full and fair appeal. The weeks after the letter arrives often shape the whole case.

Free review of your denial letter (310) 853-3461

Disability denial? We'll review your denial letter and claim file free. Disability insurance matters may be referred to, or handled with, another firm.

The letter arrives. The clock starts when you receive it.

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The appeal clock

How long do you have to appeal?

Pick the plan and the date the letter reached you. The dial shows the federal minimum.

Federal rules set the shortest appeal window a plan may give you, and the deadlines the plan must meet once you appeal. Your plan can give you more time, but generally not less. Your denial letter has to state the actual time limit, so check it against what you see here.

Which plan denied you?
Which letter is this?
The window runs from when you receive the denial. Not sure when that was? Use the date printed on the letter, the earlier of the two.
Your appeal window At least 180 days

For a disability claim, the plan must give you at least 180 days after you receive the denial to appeal.

29 C.F.R. § 2560.503-1(h)(3)(i), (h)(4)
Then the plan must decide Within 45 days

After it receives your appeal. It can take up to 45 more days for special circumstances, but only if it tells you in writing before the first 45 days end. Some multiemployer plans decide at quarterly board meetings instead.

29 C.F.R. § 2560.503-1(i)(1)(i), (i)(3)
Also good to know New evidence comes to you first

Before denying a disability appeal, the plan must give you any new evidence or new reasoning, free of charge and early enough for you to respond. Disability insurance matters may be referred to, or handled with, another firm. Your first review of the letter and claim file is free.

29 C.F.R. § 2560.503-1(h)(4)

Generally. Check your plan. These are federal minimums for plans covered by ERISA, not your plan's actual deadline. Plans can allow more time, some have more than one level of appeal, and some situations follow different rules. File well before any deadline, and keep proof of the date you sent your appeal. This tool does not give legal advice.

Read the letter

What your denial letter must tell you

A plan can't just say no. It has to say why, and what you can do about it.

ERISA requires every plan to explain a denial in writing, in words you can understand, and to offer a full and fair review. Select a numbered mark on the sample letter, then look for the same items in yours.29 U.S.C. § 1133 · 29 C.F.R. § 2560.503-1(g)

Sample letter, not a real plan
Plan claims administratorNotice of adverse benefit determination

Re: Your claim for long-term disability benefits

We have completed our review of your claim under the Plan. Your claim is denied because the records we received do not show that you are unable to perform the material duties of your own occupation.

This decision is based on the Plan's "Definition of Disability" and "Proof of Claim" provisions, copies of which are enclosed.

To complete your claim, please send your treating physician's office notes and any functional assessment that describes your restrictions. These are needed to show what you can and cannot do at work.

You may appeal by writing to the Appeals Unit within 180 days after you receive this letter. You may submit comments, documents and records with your appeal.

If your appeal is denied, you have the right to bring a civil action under section 502(a) of ERISA.

We considered your physician's opinion but did not follow it, for the reasons explained in the enclosed review. On request, you may receive, free of charge, copies of all documents relevant to your claim.

Claims departmentEnclosures

  1. The specific reasons

    Not just "you don't qualify." The actual reasons the plan denied your claim, written so you can understand them.

    29 U.S.C. § 1133(1) · 29 C.F.R. § 2560.503-1(g)(1)(i)

  2. The plan rules it relied on

    A reference to the specific plan provisions behind the decision, so you can read the words the plan is standing on.

    29 C.F.R. § 2560.503-1(g)(1)(ii)

  3. What would fix the claim

    Any additional material or information you need to complete the claim, and why it's needed. This is often your appeal's to-do list.

    29 C.F.R. § 2560.503-1(g)(1)(iii)

  4. How to appeal, and the time limits

    A description of the plan's review procedures and the deadlines that apply to them.

    29 C.F.R. § 2560.503-1(g)(1)(iv)

  5. Your right to sue

    A statement that you can bring a civil action under ERISA § 502(a) if the plan denies your appeal.

    29 C.F.R. § 2560.503-1(g)(1)(iv) · 29 U.S.C. § 1132(a)

  6. More, for disability and health claims

    Disability: why the plan disagreed with your doctors, with vocational experts, or with a Social Security disability decision you gave it; the internal rules it used, or a statement that none exist; and that you can get your claim file free. Health: any internal rule it relied on, and for medical-necessity or experimental-treatment denials, an explanation of its medical judgment, or a statement that these are free on request; plus the fast-track process for urgent care.

    29 C.F.R. § 2560.503-1(g)(1)(v)–(vii)

Found 0 of 6 in your letter so far.

Something missing? A notice that leaves out required information can matter later. If a plan does not follow the claims rules, you may be treated as having finished its appeal process and be able to go to court. Send us the letter and we'll look. For a disability denial, we'll review the letter and claim file free. Disability insurance matters may be referred to, or handled with, another firm.

29 C.F.R. § 2560.503-1(l)

The record

The appeal is where your case gets built

What's in the file when the plan decides is generally what a judge sees later.

It's easy to treat the appeal as a form to fill out. It is closer to a trial on paper. The plan has to consider everything you send, even if it wasn't part of the first decision. So the appeal is usually the moment to get your evidence into the file a judge may one day review.29 C.F.R. § 2560.503-1(h)(2)(ii), (iv)

Your right to documents

Ask for your claim file. It's free.

On request, the plan must give you reasonable access to, and copies of, all documents, records and other information relevant to your claim, free of charge. "Relevant" is broad: anything the plan relied on, anything submitted, considered or generated in making the decision, and records showing it followed its own safeguards.

  • The claim file: medical reviews, reports from consultants, notes, and the documents behind the denial.
  • The plan documents: ask the plan administrator in writing for the summary plan description, the plan document and the latest annual report. The plan may charge a reasonable copying fee for these. If it doesn't respond within 30 days, a court may order it to pay up to $110 a day, in its discretion.
  • Put it in writing, keep a copy, and note the date you sent it.
29 C.F.R. § 2560.503-1(h)(2)(iii), (m)(8) · 29 U.S.C. §§ 1024(b)(4), 1132(c)(1) · 29 C.F.R. § 2575.502c-1
Why the record matters

The file closes. Fill it first.

If the plan denies your appeal and you sue for benefits under ERISA § 502(a)(1)(B), courts generally review the decision mainly on the record the plan had. Adding new evidence in court is often limited. That's why the appeal matters so much.

  1. Your claim form and first records Start
  2. The plan's reviews and the denial First decision
  3. Your appeal: records, statements, proof Your chance
  4. The plan's final decision Record closes

After this, a court generally looks back at what's in the file.

29 U.S.C. § 1132(a)(1)(B)

Appeal first, then court

Courts generally require you to finish the plan's appeal process before you sue for benefits. If the plan didn't follow the claims rules, you may be treated as having finished it. For disability claims the plan must follow the rules strictly, with a narrow exception for minor slips.

29 C.F.R. § 2560.503-1(l)

How a judge looks at the denial

If the plan gives its decision-maker discretion, courts generally ask whether the denial was reasonable. If not, the judge decides the question fresh. For insured life and disability coverage of California residents, state law generally voids clauses that give the insurer that discretion.

Cal. Ins. Code § 10110.6

Where a benefits case is heard

A claim for benefits due under the plan can be filed in state or federal court. ERISA benefit cases are generally decided by a judge, not a jury, and a court may award attorney's fees and costs to either side, in its discretion.

29 U.S.C. § 1132(e)(1), (g)(1)

Five kinds of plans

Five plans. Five ways a no happens.

The rules share a spine. The fights look different.

ERISA generally covers benefit plans that private employers offer, and the same claims rules apply to all of them, with extra protections for disability and health claims. Government and church plans are generally not covered. Not sure whether ERISA applies to yours? Our guide to ERISA explains the basics.29 U.S.C. §§ 1003(b), 1133

Disability · LTD and STD

Long- and short-term disability

Group disability coverage through work is usually an ERISA plan, whether it pays for a few months or until retirement. A denial can come at the start, or years in, when an insurer stops paying monthly benefits.

What often goes wrong
  • The insurer says you can do your own job, or later, "any" job. Many policies tighten the definition after a set period.
  • A doctor who never examined you reviews the file and disagrees with your treating doctor.
  • A limit for mental health or "self-reported" conditions, or a pre-existing condition exclusion.
  • Benefits are reduced by offsets, such as Social Security disability benefits.
Time to appeal
At least 180 daysafter you receive the denial
Plan decides appeal
45 daysplus up to 45 more, with written notice

Free review of your denial letter and claim file

Send us the denial letter and, if you have it, the claim file. We'll review both at no cost and tell you what we see and what to do next.

Disability insurance matters may be referred to, or handled with, another firm.
Request a free review
29 C.F.R. § 2560.503-1(g)(1)(vii), (h)(4), (i)(3)(i)

Pension and retirement

Pension and retirement benefits

A pension plan can turn down an application, start benefits late, or pay less than you earned. These disputes usually come down to records and the plan's formula.

What often goes wrong
  • Years of work aren't counted, often over breaks in service or a job change.
  • The plan says you never vested.
  • The benefit is figured with the wrong pay, hours or formula.
  • A survivor or spouse benefit is disputed, or old records were lost in a merger.
Time to appeal
At least 60 days180 if the plan itself decides you're not disabled for a disability pension
Plan decides appeal
60 daysplus up to 60 more, with written notice
29 C.F.R. § 2560.503-1(h)(2)(i), (i)(1) · DOL Benefit Claims FAQ A-9

Health coverage

Health coverage through work

A health plan can refuse to approve care before you get it, or refuse to pay after. Urgent care claims move on a much faster clock.

What often goes wrong
  • "Not medically necessary."
  • "Experimental or investigational."
  • Prior-approval or out-of-network disputes.
  • Coverage is canceled back to an earlier date (a rescission).
Time to appeal
At least 180 daysafter you receive the denial
Plan decides appeal
72 hours to 60 days72 hours urgent; 30 days before care; 60 days after care

After the internal appeal, group health plans that are not "grandfathered" generally must also offer an independent external review of certain denials, such as those based on medical judgment and rescissions. Under the federal process, you generally have four months after the final denial to ask for it. In California, insured coverage (not a self-funded employer plan) generally goes through the state's Independent Medical Review instead, run by the Department of Managed Health Care or the Department of Insurance, usually requested within six months.

29 C.F.R. § 2560.503-1(h)(3)(i), (i)(2) · 29 C.F.R. § 2590.715-2719 · Cal. Health & Safety Code § 1374.30(k) · Cal. Ins. Code § 10169(k)

Life insurance

Life insurance through work

Group life and accidental death coverage is often part of an ERISA plan. A family usually learns about a problem at the worst moment, when a claim is filed.

What often goes wrong
  • The insurer says coverage ended with the job, and conversion rights weren't explained.
  • Premiums came out of pay, but required health questions were never approved.
  • An exclusion is applied to an accidental death claim.
  • Competing claims over who is the beneficiary.
Time to appeal
At least 60 days180 if the claim turns on whether you're disabled, such as a premium waiver
Plan decides appeal
60 daysplus up to 60 more, with written notice
29 C.F.R. § 2560.503-1(h)(2)(i), (i)(1) · DOL Benefit Claims FAQ A-13 · Cal. Ins. Code § 10110.6

Severance

Severance plans

Some severance programs are ERISA plans and some are not. It generally depends on whether the employer runs an ongoing program that needs administration, rather than making a one-time payment. If it is an ERISA plan, the claims and appeal rules apply.

What often goes wrong
  • The plan says you quit, or were let go "for cause," instead of laid off.
  • Payment is held up over a release you haven't signed.
  • The plan was changed shortly before the layoff.
  • The wrong years of service go into the formula.
Time to appeal
At least 60 daysafter you receive the denial
Plan decides appeal
60 daysplus up to 60 more, with written notice
29 C.F.R. § 2560.503-1(h)(2)(i), (i)(1)

Fired or pushed out to stop a benefit?

ERISA § 510 makes it illegal to fire, discipline or discriminate against you for using a benefit, or to keep you from getting one you were on track to earn, such as a pension about to vest. California employment claims may apply too.

29 U.S.C. § 1140

What to do now

Four things to do this week

Each one protects your appeal.

  1. Circle the deadline

    Write down the date the letter reached you and the appeal deadline it states. Plan to file well before it, and keep the envelope.

    29 C.F.R. § 2560.503-1(g)(1)(iv)

  2. Ask for the file, in writing

    Request your claim file and the plan documents. Keep a copy of your request and note the date you sent it.

    29 C.F.R. § 2560.503-1(h)(2)(iii) · 29 U.S.C. § 1024(b)(4)

  3. Gather what's missing

    Start on whatever the letter says is missing: medical records, a statement from your doctor, your job description, pay or service records.

    29 C.F.R. § 2560.503-1(g)(1)(iii)

  4. Talk to us before you file

    The appeal is often the last chance to add evidence. A free review of your letter is a good place to start.

    Free case review

Questions

Denied ERISA claims, answered plainly

My ERISA claim was denied. Can I sue right away?

Usually not. Courts generally require you to finish the plan's appeal process first. If the plan didn't follow the federal claims rules, you may be treated as having finished it. Either way, the appeal is where you build the record a judge may later review.

29 C.F.R. § 2560.503-1(l) · 29 U.S.C. § 1132(a)(1)(B)
How long do I have to appeal?

At least 180 days for group health and disability claims, and at least 60 days for other plans, such as pension, life and severance plans. The window runs from when you receive the denial. Your letter must state the actual deadline, and your plan may give you more time. Try the appeal clock above.

29 C.F.R. § 2560.503-1(h)(2)(i), (h)(3)(i), (h)(4)
Is there a deadline to file a lawsuit?

ERISA doesn't set one for benefit claims. Many plans set their own deadline in the plan terms, and otherwise courts borrow a time limit from state law. For disability claims, the final denial letter must describe any deadline the plan sets for suing and the date it runs out. Don't wait to find out.

29 C.F.R. § 2560.503-1(j)(4)(ii)
Can I get my claim file for free?

Yes. On request, the plan must give you copies of all documents, records and other information relevant to your claim, free of charge. Ask in writing and keep a copy.

29 C.F.R. § 2560.503-1(h)(2)(iii)
Can someone handle the appeal for me?

Yes. Plans must let you act through an authorized representative, though they can ask you to fill out a form naming that person. A lawyer can request the file, gather evidence and write the appeal with the later lawsuit in mind.

29 C.F.R. § 2560.503-1(b)(4)
My disability claim was denied. Can you help?

Start with a free review of your denial letter and claim file. We'll tell you what we see and what to do next. Disability insurance matters may be referred to, or handled with, another firm. Our long-term disability guide walks through the appeal.

What does it cost to talk with you?

The consultation is free. We work on contingency: our fee is a percentage of what we recover for you. How case costs are handled is spelled out in your written fee agreement.

Free case review

Bring the letter. We'll read it with you.

A denial letter, an appeal deadline, a claim file: any one of them is enough to start.
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Attorney advertising.This page is general information, not legal advice. Every plan is different.Contacting us does not create an attorney-client relationship.Disability insurance matters may be referred to, or handled with, another firm.

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