How to File an ERISA Claim
Filing a disability claim under an employer-sponsored benefit plan is not the same as applying for state disability or Social Security benefits. If your benefits are provided through your job, they are often governed by ERISA—the Employee Retirement Income Security Act of 1974. While ERISA was designed to protect employee benefits, in practice its claims procedures are highly technical and full of traps for the unwary.
This guide explains what an ERISA claim is, how to file one properly, what rules and regulations apply, and why legal guidance can make all the difference when your livelihood is on the line.
What Is an ERISA Claim?
At its core, an ERISA claim is a request by a participant or beneficiary of an employer sponsored benefit plan for the payment of a benefit owed under the terms of the plan. This could include health insurance, life insurance, retirement benefits, or, most commonly in our practice, long-term disability benefits.
Unlike other types of insurance claims, an ERISA claim is not purely contractual. It is governed by federal law1 with strict timelines, required notices, and specific rules about appeals.2 Because of these added layers, even a straightforward benefit claim can quickly become complex.
Understanding ERISA Claims Procedures
ERISA claims procedures are set out in Department of Labor regulations that apply to most employee benefit plans. These rules dictate how quickly insurers must respond to requests for benefits (claims), and what rights you have if your claim is denied.
For disability benefits, the regulations require insurance companies to make a decision within 45 days of the claim, though they can extend the deadline by 30 days twice if they provide valid reasons, for a total of 105 days.3 If they request information from you, the claimant and have to wait for it, the insurers can “toll” their deadline to decide the claim, resulting in additional delays.4
If the insurer denies your claim for disability benefits, it must provide you with a written explanation (adverse benefit determination) cites the specific reasons, the plan provisions relied upon, and the evidence considered.5
Many courts, including in the 9th Circuit, have stated that the insurer must explain “why” the evidence you proffered in support of your claim was insufficient, or “why” your medical evidence was unreliable. In practice, most insurers fail to explain with specificity the “why” of its rejection of your medical evidence. See, e.g., Saffon v. Wells Fargo Co. Long Term Disability Plan (9th Cir. 2008) (argued by Cassie Springer Ayeni, chastising MetLife for not explaining “why” the treating physician’s report and an MRI “did not amount to ‘objective clinical information’ or was not ‘clear’,”), available at https://caselaw.findlaw.com/court/us-9th-circuit/1106709.html
It is important to understand that the appeal process is not optional. Under ERISA, you must exhaust the internal appeals process before filing a lawsuit in federal court. Failing to follow this step can end your case before it ever begins.
Preparing to File
When people ask how to file an ERISA claim, the most important advice is to prepare thoroughly before you even submit the paperwork. Insurers will require medical documentation, employment records, and often statements from your treating doctors. Gaps in the evidence at this early stage can lead to delays or outright denials.
The Employee Benefits Security Administration lays out some beginning steps to file a claim for disability benefits in its publication, “Filing a Claim for Your Disability Benefits.”6
We at Springer Ayeni believe strongly that preparation is key. You should:
- Make sure you have a copy of your Long-Term Disability insurance policy, which may include a summary plan description. These documents set out the rules for coverage, definitions of disability, and deadlines.
- Talk with your treating physicians to ensure they are willing to support your claim with detailed medical records and, by completing necessary forms, and, when appropriate, written statements.
- Gather employment records that describe your job duties, since the insurer will evaluate whether you can perform the material and substantial duties of your position.
- Prepare a statement outlining why you are unable to do your job, and how your disability affects your everyday life as well. This will help you get your thoughts organized when the insurer asks you to explain why you can’t work.
Completing the Forms
Most insurers require that you fill out their own claim forms, which often include separate forms for you, your employer, and your physician. Some people search for an “ERISA complaint form,” but in reality, each insurer provides its own forms tailored to its policy.
Be careful when completing these forms. Insurers scrutinize every word. For example, if you minimize your symptoms in an effort to appear resilient, the insurer may use that against you. At the same time, exaggeration can harm your credibility. Accuracy, honesty, and consistency are critical.
Also be aware that the forms provide very narrow boxes to explain complicated conditions. Do not feel limited to the box.Instead, if needed, attach an addendum that continues your written answer on a separate page.
Submitting Medical Evidence
The heart of most ERISA disability claims procedures is the medical evidence. Insurers want to see not only a diagnosis but also documentation of how your condition limits your ability to work:
- For physical conditions, this may include imaging, lab results, or surgical reports.
- For mental health conditions, detailed treatment notes and evaluations can be just as important.
- For progressive conditions, the months or years leading up to your disability claim will be scrutinized to analyze how you were previously able to work but currently are not.
In the months leading up to a claim, be sure to communicate regularly with your physician about your symptoms so that they, and your doctor’s recommendations and treatment, are actually in your medical records when the time comes for the insurer to review them.
Do not assume that the insurer will collect everything for you. Even though you may sign a release, insurers often fail to request or review every record. Submitting complete documentation yourself helps ensure that your case is evaluated fairly.
Following ERISA Claims Regulations
ERISA disability cases are governed by strict federal regulations that outline mandatory timelines, notices, and appeals.7 For example:
Claims must be decided within a maximum of 105 days after submission (but this may be tolled if the insurer asks the claimant for information and it is waiting to receive that information).8
Denials must include specific reasons and instructions for appeal.9
Appeals must be filed within 180 days of the denial letter.10
Insurers must give you access to all relevant documents upon request. When you make the request, be sure to ask for everything relevant to your claim, which can include claim notes, medical reports, surveillance footage, and even audio recordings of phone calls. In fact, the Employee Benefits Security Administration specifically informed Cassie Springer Ayeni that audio recordings are relevant to a claim file and must be disclosed.11
Missing a deadline or failing to request documents can severely weaken your case, and even can terminate your right to your benefits altogether. That is why it is important to seek competent ERISA legal assistance as soon as possible, even before submitting an initial application, and certainly immediately after receiving a denial letter.
The Appeal Process
If your claim is denied, you have the right to file an internal appeal. This is not simply a chance to re-argue your case; it is your last opportunity to add evidence to the record. Under ERISA, the administrative record created during the claim and appeal stages is usually the only evidence about the facts of your disability that a federal judge will review if you later file a lawsuit.
Because of this, it is critical to submit everything you may ever want considered at this stage: updated medical records, statements from your doctors, vocational evaluations, witness statements, symptom logs, pictures, or video evidence, etc.
Filing an appeal without a clear strategy can be disastrous. Once the record closes, you may never get another chance to add the missing evidence.
How to File an ERISA Complaint
If your appeal is denied, your next step may be to file a lawsuit in federal court. At this stage, some people search for how to file an ERISA complaint, but it is not as simple as filling out a form online. You need an attorney for this process. A complaint must be drafted in compliance with federal court rules, filed in the correct jurisdiction, and served on the appropriate parties. There are certain mandatory requirements for all federal lawsuits, and failing to comply with them may result in a dismissal of your case.
Why Legal Guidance Matters
Filing an ERISA claim can feel deceptively simple: fill out forms, attach records, wait for an answer. But behind the scenes, insurers rely on teams of claims administrators, nurses, and physicians to scrutinize your file, and the forms are a very small percentage of what they are reviewing when building your “claim file.” In my decades of experience, I have seen, time after time, claims handlers searching for a “reason to deny” rather than evaluating all of the evidence as a “reason to approve.”
Unfortunately, because of the limitations of ERISA law, the cards are often stacked against an ERISA plaintiff in court, so it is important to get the evidence right from the get-go. Knowing how to file an ERISA claim correctly, from the very beginning, is critical. Working with an attorney ensures that your claim is presented in the strongest possible way. Legal guidance can help you avoid missed deadlines, frame your medical evidence effectively, and preserve your rights for litigation if needed.
Bringing It All Together
Filing for disability benefits under an employer-sponsored plan is not just about paperwork. It is about protecting your financial security when illness or injury prevents you from working. Understanding what an ERISA claim is, how the claims procedures work, and what evidence is required can make the difference between approval and denial.
The process may seem overwhelming, but you do not have to face it alone. At Springer Ayeni, we have guided clients through ERISA disability claims procedures for more than two decades. We know how insurers operate, and we know how to build strong cases under the law.
If you are preparing to file a claim, facing a denial, or simply want to understand your options, reach out to us. We can help you navigate the process with clarity, strategy, and compassion, so that you can focus on your health while we focus on protecting your benefits.
1 Employee Retirement Income Security Act (ERISA). U.S. Department of Labor. (https://www.dol.gov/general/topic/retirement/erisa),
2 Filing a Claim for Your Disability Benefits. U.S. Department of Labor, Employee Benefits Security Administration. https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our activities/resource-center/publications/disability-benefits-claim-filing.pdf
3 29 CFR Sec. 2560.503-1(f)(3). Cornell Law School Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/2560.503-1
4 29 CFR Sec. 2560.503-1(f)(4). Cornell Law School Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/2560.503-1.
5 29 CFR Sec. 2560.503-1(g). Cornell Law School Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/2560.503-1.
6 Filing a Claim for Your Disability Benefits. U.S. Department of Labor, Employee Benefits Security Administration. https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our activities/resource-center/publications/disability-benefits-claim-filing.pdf
7 29 CFR Sec. 2560.503-1(f)-(g). Cornell Law School Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/2560.503-1
8 Benefit Claims Procedure Regulations, C-3. U.S. Department of Labor. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource center/faqs/benefit-claims-procedure-regulation
9 Benefit Claims Procedure Regulations, C-16. U.S. Department of Labor. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource center/faqs/benefit-claims-procedure-regulation
10 CFR Sec. 2560.503-1(f)(3). Cornell Law School Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/2560.503-1
11 Information Letter 06-14-2021. U.S. Department of Labor, Employee Benefits Security Administration. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource center/information-letters/06-14-2021
