Leaving a Job Due to Health Reasons
For many professionals, work is not only a source of income but also a core part of identity. When serious illness or injury interrupts your ability to perform your job, the decision to step away can be overwhelming. Leaving a job due to health reasons often involves a combination of medical, financial, and legal considerations that are not immediately obvious to employees or their families and are not easy to undertake alone.
This article explains common reasons for leaving a job due to health concerns, what protections and benefits may apply, and steps to take before making a final decision to leave work, or before submitting a disability insurance claim.
Common Reasons for Leaving a Job Due to Health Concerns
Not all health challenges are visible, and not all evolve to disabilities. Some are acute problems that come on suddenly, but many are chronic conditions that slowly erode the ability to work. No one begins a career with a mindset that it will be cut short by a disability, so even the process of acknowledging that health concerns are gradually impairing the ability to get your normal job done can take some time. Some health conditions that might eventually cause a disability include chronic fatigue, increasing pain, or neurological disorders that might impede cognitive acuity.
According to the Council for Disability Income Awareness, the most common reasons for long-term disability claims are:
- Musculoskeletal disorders (25%)
- Injuries such as fractures, sprains, and strains of muscles and ligaments (13%)
- Cancer (12%)
- Mental health issues (10%)
- Circulatory (heart attack, stroke) (8%)1
Yet many other health conditions, such as long-COVID, ME/CFS, neurological disorders like Parkinson’s Disease, and more can cause someone to leave the workforce. Each of these conditions can make regular attendance, concentration, and stamina nearly impossible, even for employees who are highly motivated to keep working.
Considering a Disability Claim Before Resignation
Before you submit a resignation letter, it is critical to consider whether you have a disability income insurance policy through your employer. Typically, your last day of work serves as your first date of disability, as you need to be a covered employee at the time of your date of disability. Resigning too soon might jeopardize your disability claim.
For many employees, the question is not only whether they can keep working, but also how they will support themselves if they cannot. Filing for disability insurance benefits before resigning can be a critical step.
Employer-sponsored long-term disability benefits may fill the gap. These benefits usually replace 50–70% of pre-disability income, subject to offsets for other sources of income such as state disability benefits, workers’ compensation benefits, or Social Security Disability Benefits, to name a few. Speaking with an ERISA attorney before finalizing your decision to leave work can ensure you do not unintentionally waive coverage.
Leaving a Job Due to Mental Health Reasons or Physical Conditions
Before deciding that you will leave your job and file a disability claim, it is important that you receive regular and appropriate care with a medical provider. For mental health disability claims, that usually means seeing a therapist on a regular basis, and working with an MD to explore medication options.
It is important to note that although a workplace can and frequently does contribute to the mental health condition, the mental health disability must be ongoing even outside of a particular workplace for it to rise to the level of a disability claim. Therefore, speak to your doctor not just about the stresses of the workplace, but how you might be struggling with your everyday activities as well.
Likewise, for physical disabilities, be sure that your doctor knows the “full picture” of how your health affects your life, both in and out of the workplace. Describe to your doctor what activities are difficult to accomplish, and what the effect is when you have worked a full day at the office. It is important for your doctor to understand how limiting your health concern is, since you will be asking him or her to fill out forms in support of your long-term disability claim.
Practical Steps Before Resigning
If your health is forcing you to consider leaving your job, these steps can help protect your interests:
- Review your benefit plan documents. Locate copies of your disability insurance policies and review them to understand what is considered a disabling condition. You can also consult with an attorney at Springer Ayeni for an analysis of your policy’s particular terms and conditions.
- Secure medical documentation. Ask your treating physicians to take down detailed records of your condition and its impact on your job performance, so that your medical records tell the complete story of your impairment.
- Consider disability benefits applications before resigning. Filing while still actively employed can preserve eligibility under ERISA plans.
- Consult with an attorney. Legal advice can help you strategize the best way to step back from working, and what might be needed for a successful long-term disability claim.
Emotional and Practical Considerations
Leaving a job for health reasons is not just a legal or financial matter; it is also an emotional one. Many employees struggle with guilt, fear of stigma, or anxiety about the future. The National Institute of Mental Health provides resources for coping with mental health challenges.2 Organizations like NAMI offer peer support groups for individuals facing job loss due to illness.3 Seeking support can make the transition less isolating.
Bringing It All Together
Leaving a job due to health reasons is rarely a simple decision. Whether the challenge is physical illness, injury, or mental health, the consequences affect every aspect of life. Understanding legal protections, evaluating disability benefits, and taking the right steps before resigning can safeguard both your financial security and your peace of mind.
At Springer Ayeni, APLC, we have spent more than two decades helping professionals navigate this difficult crossroads. If you are facing the possibility of leaving work due to health concerns, we are here to provide clear advice, protect your rights, and support you through the transition.
References:
1 Disability Statistics. Council for Disability Income Awareness.
https://thecdia.org/disability-statistics/
2 Caring for Your Mental Health. National Institute of Mental Health.
https://www.nimh.nih.gov/health/topics/caring-for-your-mental-health.
3 Workforce: Peer Support Workers. National Alliance on Mental Illness. https://www.nami.org/advocacy/policy-priorities/improving-health/workforce-peer support-workers/
Read More
Understanding Disability Insurance
When a serious illness or injury prevents you from working, the financial consequences can be overwhelming. That is why disability insurance exists: to protect your income when you cannot earn a paycheck due to your serious and chronic medical condition. For many people, this benefit is just as important as health insurance or life insurance, yet it is often overlooked until a crisis occurs because almost no one anticipates a life-altering disability interrupting their anticipated career trajectory.
This article explains what disability insurance is, the types of coverage available, what it costs, and why it matters for employees.
What Is Disability Insurance?
Disability insurance is a type of income protection that pays a portion of your earnings if you are unable to work due to a qualifying medical condition. Unlike health insurance, which covers medical bills, disability insurance provides monthly income replacement so you can continue paying for your life expenses, which may be much more than just housing, food, medical expenses, and essentials.
Types of ERISA Disability Insurance Coverage
If you work for a private employer that provides disability insurance benefits, there are two main categories of coverage: short-term and long-term. Short-term coverage usually lasts a few weeks or months, often bridging the gap while you recover from a temporary condition. Long-term coverage provides benefits for years, sometimes up to retirement age, if your disability prevents you from returning to work.
Employer-sponsored benefit plans often include long-term disability insurance, particularly for employees in the medical, legal, tech, and finance fields. For private employers (as opposed to those working for the government or religious institutions), plans are typically governed by ERISA, the federal law that regulates employee benefit programs. For those without access to an employer plan, private disability insurance can be purchased individually.
Disability Income Insurance
The term “disability income insurance” emphasizes what the policy provides: replacement of a portion of your lost wages. Policies commonly pay between 50% and 70% of your prior income, subject to caps (maximum benefits) and offsets for other income sources.
Your particular disability insurance policy usually has a “Schedule of Insurance” page near the front that outlines the percentage of pre-disability earnings covered, and maximum benefit, the minimum benefit after offsets, and the maximum duration. Other sections of the policy will itemize the offsets for “income from other sources,” which typically include any state disability benefits, Social Security Disability Income for you and your dependents, some Workers’ Compensation benefits, and perhaps several other types of income you may receive while disabled. You should read this section of the policy carefully before signing any kind of severance agreement, before taking a retirement distribution, or before earning any kind of income from another source.
Additionally, you should be careful not to sign any separation agreement that waives your right to ERISA (Employee Retirement Income Security Act) claims, because if you do you could waive your right to your ERISA Disability Insurance Claim(s). Rather, talk with your employer about carving out your ERISA disability claims from any separation agreement you may be asked to sign.
Incredibly, the Social Security Administration notes that one in four 20-year-olds today will experience a disabling condition before retirement age.1 While Social Security Disability Insurance is an important start, without supplemental ERISA disability insurance policies, many workers, especially those living in high cost of living areas, could not live on the SSDI benefit alone, which has a relatively low maximum monthly benefit. The ERISA disability policy provided by your employer should bridge the gap between the public benefit and a higher percentage of your pre-disability earnings.
Individual and Private Disability Insurance
While group coverage through an employer is common for most professionals, particularly those in medical, legal, financial, and tech, high income earners may choose to supplement their group (ERISA) policies with their own individual disability insurance. An individual policy offers portability (you keep it even if you change jobs) and customization of terms such as waiting periods, benefit periods, and definitions of disability.
Most major insurance companies offer options for applying for supplemental disability coverage so that you can protect more of your income than your ERISA disability plan may provide.2
If you are considering supplemental coverage, it is wise to request long-term disability insurance quotes from multiple carriers. This allows you to compare definitions of disability, benefit percentages, elimination periods, and exclusions.
Quotes also reveal how premiums differ depending on whether you choose a policy that defines disability in terms of your “own occupation” (unable to perform your current profession) versus “any occupation” (unable to perform any job for which you are reasonably qualified).
Because the definitions and terms vary widely, reviewing long term disability insurance quotes with the help of an attorney or trusted advisor ensures you understand what you are buying.
Insurance for Disability: Common Misconceptions
Many people assume that Social Security Disability Insurance or workers’ compensation will be enough to protect them. In reality, these programs are limited. SSDI requires that your condition be expected to last at least 12 months and prevent you from performing any substantial gainful activity.3 Moreover, Social Security benefits are subject to a rather low maximum monthly benefit that could be a fraction of what professionals are earning in high cost of living areas, such as in Northern California.
Workers’ compensation only applies if your disability is caused by your job, and benefits may be limited or disputed. ERISA or private disability insurance policies fill this gap by protecting you from illnesses or injuries unrelated to your occupation, and by providing a higher monthly benefit, and often with a less stringent definition of disability.
Why Disability Insurance Matters
Disability insurance is not about expecting the worst; it is about preparing for the unexpected.4 Illnesses such as cancer, multiple sclerosis, or heart disease, as well as injuries from accidents, can interrupt your expected career trajectory, causing you to leave the workforce much sooner than anticipated.
The reality is that income protection is one of the most important financial safeguards for individuals and families. Without it, even a short-term disability could drain savings, while a long-term condition could derail life and even retirement plans entirely.
Bringing It All Together
Disability insurance may not be a benefit most people think about until they need it, but it is essential to financial security. Whether you are evaluating long term disability insurance quotes, reviewing your employer’s group disability insurance coverage, or exploring private disability insurance as a supplement to your employer-sponsored ERISA plan, understanding your options is key.
At Springer Ayeni, we have guided professionals for more than two decades through the complexities of disability insurance coverage, from initial claims to appeals and litigation.
If you are unsure about what coverage you need—or if you are facing challenges with a claim—we are here to provide clarity, strategy, and compassionate advocacy.
References:
1 Social Security Fact Sheet. Social Security Administration.
https://www.ssa.gov/news/press/factsheets/basicfact-alt.pdf
2 Supplemental individual disability income insurance. (24 July, 2025). Guardian. https://www.guardianlife.com/disability-insurance/supplemental
3 Disability Evaluation Under Social Security. Social Security Administration. https://www.ssa.gov/disability/professionals/bluebook/general-info.htm
4 “Disability Can Strike Unexpectedly, So Be Prepared.” (2023, November 13). NASA Federal Credit Union. https://www.nasafcu.com/blog/detail/disability-can-strike unexpectedly-so-be-prepared
Read More
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.
Read More
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
Read More