The ERISA Appeal Process
If your long-term disability claim has been denied, you are not alone. Insurance companies deny many legitimate claims, often leaving employees uncertain about what to do next. Fortunately, under the Employee Retirement Income Security Act of 1974 (ERISA), you have the right to challenge the denial. This process is called an ERISA appeal process or a Request for Review, and understanding how an ERISA appeal process works is crucial to protecting your benefits.
This guide explains the ERISA appeal process in detail: how it works, what regulations govern it, what evidence you might need, and why careful preparation and the help of experienced attorneys can make or break your case.
Why the ERISA Appeals Process Matters
ERISA governs most employer-sponsored benefit plans, including long-term disability insurance. If your claim was denied, ERISA requires that you first pursue an internal appeal with the insurance company before you can file a lawsuit in federal court. This requirement is known as “exhausting administrative remedies” and ERISA requires that you receive a “full and fair review” of your ERISA appeal.1
Your ERISA appeal is not merely a requirement. It is often your last chance to add evidence to the record. Federal courts reviewing ERISA cases generally limit their review to the evidence submitted during the claim and appeal stages. If you fail to submit key medical records, vocational reports, or supporting statements now, you may not be able to use them later. The U.S. Department of Labor explains these rules in its Disability Claims Procedure Regulations, which set specific requirements for insurers and protections for employees.2
Understanding ERISA Appeals Regulations
Under ERISA’s most up-to-date regulations, ERISA plan administrators (often long-term disability insurance companies) must:
- Give you a clear explanation of why your claim was denied.
- Provide access to all documents, records, and guidelines relevant to your claim.
- Must not rely on new evidence in the appeal without giving you a chance to respond.
- Decide an appeal within a set timeframe, usually 45 days, with one possible 45-day extension.
You can review the regulatory framework at 29 C.F.R. § 2560.503-1, available at no cost through Cornell Law School’s Legal Information Institute.3
The timelines and disclosure requirements in the ERISA regulations are not suggestions; they are binding obligations on insurance administrators of ERISA disability plans.
Four Critical Steps to Perfect Your ERISA Appeal
To achieve success in an ERISA appeal, you must request and analyze the claim file following receiving the denial letter, prepare supporting evidence in support of your appeal, and submit the appeal before the 180-day deadline, as outlined in these steps:
1. Review the Denial Letter
The first step in the ERISA appeal process is carefully reviewing the denial letter. This letter must explain:
- The specific reasons for denial.
- The policy provisions relied upon.
- What additional information, if any, is needed.
- How and when you can file an appeal.4
Denial letters often cite lack of “objective evidence,” conflicting medical opinions, or surveillance reports. Understanding the insurer’s reasoning will help you target your appeal effectively.
2. Request the Claim File
Before preparing your appeal, request a complete copy of your claim file. This is your right under ERISA. The file should include medical reviews, credentials of the medical reviewers, audio files of any recorded phone conversations, vocational assessments, surveillance records, all medical records obtained, all correspondence generated or received by the insurance company during your entire claim, and internal notes made by the insurance company.
The best practice is to list each of the items you are requesting in your claim file request, rather than just stating that you are requesting the “claim file.” In case you are told that audio recordings will not be disclosed, note that The Employee Benefits Security Administration specifically informed Cassie Springer Ayeni that audio recordings are relevant to a claim file and must be disclosed.5
3. Strengthen Your Medical Evidence
The most critical part of your appeal is the medical documentation. Insurers often deny claims by arguing that the evidence does not support functional limitations. To counter this, you should provide anything helpful and relevant to your case, including:
- Updated medical records since the original denial, or any medical evidence not included in the claim file.
- Detailed statements from your treating physicians.
- Detailed statements from you setting forth your vocational and medical history.
- Detailed statements from friends, family, and colleagues about their observations of your limitations.
- Diagnostic tests, imaging, or lab results when available.
- Additional testing of functional capacity, cognitive limitations, etc.
- Explanations of why symptoms such as fatigue, pain, or cognitive impairment prevent reliable work performance.
- Photo or video evidence, where applicable.
- Reliable sources of evidence explaining your condition and its limitations.
For example, the Mayo Clinic provides in-depth information on conditions like multiple sclerosis, lupus, and chronic fatigue syndrome—illnesses that often form the basis of ERISA disability claims. Referencing credible medical sources can strengthen your appeal.
4. Address Vocational Demands
Disability under most policies is defined in terms of your ability to perform your “own occupation” or, later, “any occupation,” subject to the specific terms of your particular disability insurance policy. That means your appeal should include vocational evidence showing how your limitations prevent you from performing the material and substantial duties of your occupation, not just your job for your particular employer.
When submitting your appeal, be sure to submit a detailed job description, as well as other evidence for how your occupation may be performed in the national economy, such as descriptions from the Department of Labor Occupational Keyword Search Database6 or a vocational report. Demonstrating how your specific job demands conflict with your medical restrictions can be critical in explaining why you are disabled from your particular occupation.
Writing an ERISA Appeal Letter
An effective ERISA appeal letter is more than a simple request for reconsideration. It should:
- Identify errors or gaps in the denial letter.
- Reference the policy language and ERISA regulations in play.
- Attach all supporting evidence.
- Argue clearly why you meet the policy’s definition of disability.
- Cite to relevant legal authority analogous to your particular facts.
Because this letter forms the backbone of any future litigation, many claimants seek legal counsel to ensure it is thorough.
Timelines and Deadlines
Under ERISA claims procedures, you usually have 180 days from the date of the denial letter to file your appeal. Missing this deadline can permanently forfeit your right to the claim altogether.
Once you submit the appeal, the insurer has 45 days to make a decision, with one possible 45-day extension if they provide valid reasons. These deadlines are set by federal regulation and can be enforced in court if insurers fail to adhere to the strict deadlines.
In one of Springer Ayeni’s victories, the court held that the mandatory ERISA deadlines are bright lines, and strict adherence is required. Hasten v. Prudential, 470 F. Supp. 3d 1076 (N.D. Cal. 2020).7 There, the court wrote: “It is uncontested that the Defendant failed to decide Plaintiff’s claim within the time frames defined in the pertinent regulations. In addition, Defendant failed to follow procedures for properly requesting deadline extensions. Thus, the Court finds that Defendant did not strictly adhere to the claim handling process as required under the applicable ERISA regulations.”
Common Tactics by Insurers
During the ERISA claims administration process, at either the claims or appeals stage, insurers may:
- Send you for an “independent medical examination” by a doctor they choose.
- Conduct video surveillance.
- Rely on in-house physicians who review records without ever examining you.
- Mischaracterize or selectively quote your medical records.
Recognizing these tactics can help you and your attorney prepare stronger responses. It is important that an effective appeal address directly any flawed interpretation of your medical information, or point out where an insurer or medical reviewer may have “cherry picked” evidence to support a denial.
After the Appeal: Litigation
If your appeal is denied, your next step may be a lawsuit in federal court. At that stage, the judge will usually review only the “administrative record” or “claim file” created during your claim and appeal. That is why building a complete record during the ERISA claims and appeal process is so vital.
Why Legal Representation Is Critical
While ERISA was intended to protect employees, the reality is that the law often favors insurers. Courts may give significant deference to the insurance company’s decision unless you can prove it was arbitrary and capricious, unless the standard of review is de novo. That is why the appeal is the most important stage of the process for evidence building.
Experienced ERISA attorneys know how to frame medical and vocational evidence, cite applicable regulations and case law, and preserve issues for litigation. Without that expertise, claimants may not even be able to secure legal representation to assist with litigation. In other words, it is critical to hire experienced ERISA counsel as soon as you receive a denial letter.
Bringing It All Together
The ERISA appeal process can feel overwhelming, especially when you are already dealing with a serious medical condition. But it is also your opportunity to strengthen your claim by submitting a robust appeal complete with thorough medical evidence. By carefully reviewing your denial, gathering strong evidence, and submitting a detailed ERISA appeal letter, you can significantly increase your chances of success. It is best to do this with an ERISA lawyer at your side to handle it for you and relieve you of the significant stress this process can create.
At Springer Ayeni, we have been guiding clients through ERISA claims appeals for more than two decades. We understand the law, we know the tactics insurers use, and we are committed to fighting for the benefits our clients deserve. If your claim has been denied, we are here to help you take the next step with clarity and confidence.
1, 2, 3, 4 3 29 CFR Sec. 2560.503-1. Cornell Law School Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/2560.503-1
5 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
6 O*NET OnLine. U.S. Department of Labor, Employment & Training Administration. https://www.onetonline.org/
7 Hasten v. Prudential, 470 F. Supp. 3d 1076 (N.D. Cal. 2020). FindLaw. https://caselaw.findlaw.com/court/us-dis-crt-n-d-cal/2075810.html.
