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 MoreERISA Basic Virtual Conference by ABA Joint Committee
Please join me, my program co-chairs, panelists, and participants at the American Bar Association Joint Committee on Employee Benefits’ “ERISA Basics” Virtual Conference that will take place from December 7-10, 2020! This year covers series of discussions that span Business Law, Health Law, Labor and Employment Law, Real Property, Trust and Estate Law, Taxation, Tort Trial and Insurance Practice.
To sign up: https://www.americanbar.org/events-cle/mtg/web/403621552/
Or contact: Cassie Springer Ayeni, President of Springer Ayeni, A Professional Law Corporation @www.benefitslaw.com
#ABA #JCEB #ERISA #Employeedisabilitybenefits #disablity #ERISAlawyer #Superlawyer #Disabilityclaims #Disabilityappeals #Longtermdisability #ERISAlitigator #ERISAbayarea #Disabilitylawyer #Employeebenefitslawyer #ERISAlawfirm #SpringerAyeni #benefitslaw
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Bay Area Women Magazine features Cassie Springer Ayeni
It was an honor to be interviewed for Bay Area Women Magazine. My favorite question was “How do you maintain work/life balance?” Little did I know that my practice would prove so necessary during these unprecedented times: “I figure that everything I need to raise four children and work full-time as an attorney is what everyone at my firm needs too. I offer unlimited PTO, great benefits, four months of fully paid maternity leave, the ability to bring children in to work as needed (in fact I have brought each of my babies into work until they needed another environment), the ability to work from home, and a practical approach to parenting.” Here’s the link to “Her Firm’s Achievements & Results are Measured by the Satisfaction of Her Clients: A Conversation with Attorney Cassie Springer Ayeni.“
Read MoreErisa Counsel: The Hidden Risk of Fiduciary Exception
Today at 10 am PST, I will be on a panel discussing the topic: ERISA Counsel and Attorney-Client Privilege: What You Don’t Know About the “Fiduciary Exception” Could Hurt You. This webinar is hosted by Strafford. I look forward to the questions and discussion.
For more, see event details: https://www.straffordpub.com/products/tlgjeahgra?utm_campaign=tlgjeahgra
Read MorePersonal Injury Subrogation Claims Under ERISA
“Personal Injury Subrogation Claims Under ERISA,” my latest article in “The Verdict Magazine,” was published today by the Alameda and Contra Costa County Trial Lawyers Association. This article outlines an example of how the 9th Circuit gets ERISA.
For more visit: https://acctla.org/wp-content/uploads/2019/11/Fall2019-2-copy.pdf#page=7
Read MoreCliient Satisfaction Drives Her Firm: Meet Cassie Ayeni
Q: When did you know you would pursue a career in the legal field?
CSA: As early as junior high or high school, I felt the need to advocate for others, to make a point to stand up for the kids who were being bullied or ostracized. I also realized around the same time that I truly enjoyed writing, reasoning, and debating. The law seemed a natural fit: I could use my skills to make a palpable difference in people’s lives. I had settled on a career in law by the time I was 16 and never looked back.
Q: Can you explain what types of cases an ERISA Attorney handles and why you chose this area of law?
CSA: I primarily help people with their employer-sponsored disability benefit claims. ERISA governs all private employer benefit plans, not just pension plans. Many employers provide disability benefit plans in addition to health and pension benefits. In fact, 65% of ERISA litigation is over denied disability benefit claims. The plans are often insured, and clients typically come to me after they stop working, apply for disability benefits to the insurance company, and are denied. I then step in to try to get their disability benefit income restored while they focus on their health.
Q: What is your approach or philosophy to winning or representing a case?
CSA: I lead with kindness. I want to understand truly what my clients have gone through medically, economically, and emotionally to get to this point in their lives, and how I can help. In representing a client, I am there for that person: I am responsive and listen with an open heart. I believe this the secret to winning a case as well – if I am doing my job right, I am painting a picture of the person and the case to help the court appreciate why my client is deserving of their disability benefits. I have the paintbrush and paint ready because I have spent months getting to know my clients and researching the law. And I also aim to be the best-prepared lawyer in the room with the most compelling brief … that helps too.
Q: If we interviewed all your past clients … what is “one” common word that comes up when they describe working with your law firm?
CSA: Compassion
Q: What are some of the most popular topics you are asked to lecture on?
CSA: I speak frequently on ERISA topics, especially in my current role as the co-chair of the ABA’s Employee Benefits Committee. I love presenting to newer attorneys about the fundamentals of ERISA litigation, because I am eager to energize attorneys about how engaging ERISA work is. ERISA is fun! The law is always evolving, providing constant intellectual stimulation, and practicing ERISA law is also a great way to help people in need. I also enjoy speaking to women about re-defining what it means to be a successful litigator, and how to challenge traditional law firm standards to achieve a better work-life balance.
Q: What advice would you give to young women who want to pursue a career as an Attorney?
CSA: Any woman who wants to pursue a career as an attorney should make sure that her potential work environment values diversity and inclusion, fosters a sense of belonging, and creates opportunities for women at every turn. If she is unable to find that environment, she should open her own law firm and create those opportunities herself.
Q: How do you maintain a work/life balance?
CSA: Being the owner of my firm allows me to make up the rules: I look to the best practices of progressive companies and pick policies that I believe are imperative to work/life balance for everyone. I figure that everything I need to raise four children and work full-time as an attorney is what everyone at my firm needs too. I offer unlimited PTO, great benefits, four months of fully paid maternity leave, the ability to bring children in to work as needed (in fact I have brought each of my babies into work until they needed another environment), the ability to work from home, and a practical approach to parenting … like closing the office on Halloween and Valentine’s Day so that we can all attend class parties without rushing to or from work. I, of course, avail myself of each of these policies, which is why I created them in the first place. That’s not to say that I don’t wake up early to work for a bit so that I can focus fully on my kids to take them to school, or grab a few hours on the weekend to pound out a brief, but family always comes first, for me and for everyone who works at Springer Ayeni.
Q: What’s one lesson you’ve learned in your career that you can share with our audience?
CSA: I have always learned to be myself. If you are authentic, you are compelling as an advocate and a counselor: you listen and communicate better when you are not spending energy on worrying about how you should come across. I also believe in the power of preparation. If you are committed to doing your best and preparing your utmost, then even a negative outcome cannot be met with regret, but a positive outcome is much more likely. And if you’re nervous before a court appearance or speaking engagement, just take a breath and realize that even in a worst-case scenario, you will survive and move forward … we all do.
Q: What are some of the challenges you feel women face today?
CSA: Looking at women lawyers only, there is much progress to be made. As Joan Williams at the UC Hastings Center for WorkLife Law has analyzed convincingly, women lawyers (and women in other fields too) are asked to “prove it,” then “prove it again.” In other words, women need to do the job before getting the promotion, whereas men are promoted based on potential. This is a major obstacle to women’s promotion and needs to be addressed systematically.
Five Things About Cassie Springer Ayeni
1. If you could talk to one famous person past or present, who would it be and why?
There are so many! But if I had to pick one it would be Harriet Tubman – her courage and vision even in the face of medical problems were and are awe-inspiring.
2. What’s your favorite holiday? Why?
Valentine’s Day! I don’t view it as just a romantic holiday, but as a day to express to those around you how much you care.
3. If you were a superhero, what would your special powers be?
Time-traveling. That would be magical!
4. What app can’t you live without?
Facebook – it has allowed me to make great connections with other lawyer moms – lawmas!
5. Favorite food to eat?
Strawberries. Now, then, forever, and always.
For More: https://bayareawomenmag.com/news/view/11665/Her_Firms_Achievements_-_Results_are_Measured_by_the_Satisfaction_of_Her_Clients_A_Conversation_with_Attorney_Cassie_Springer_Ayeni
Read MoreSelma Blair and Our Culture of Disability Disbelief
Selma Blair walked the red carpet at the 2019 Vanity Fair Oscar Party – a vision of radiant beauty sporting a dazzling cane. She then delivered a powerful interview on Good Morning America discussing her Multiple Sclerosis diagnosis, a disease of the central nervous system that can cause pain, fatigue, and problems with balance and muscle control, among others. Her presence and determination shined through, reminding me of many of my clients who battle through horrific symptoms to keep working as long as possible, only to be disbelieved by a disability insurance company when they finally need to stop working.
Ms. Blair called MS the “snowflake disease because it’s different – like a fingerprint – for everyone. Not one size fits all.” She also noted that although she has battled MS for years, including with its current manifestation of spasmodic dysphonia – affecting her speech – that “it can be very different in a year, for the better.” The fluctuating symptoms of diseases like MS often make it difficult for a disability insurer to grapple with the notion of disability. Disability insurers like to operate in extremes: either you are totally disabled or you are not; either you can never run an errand or you’re capable of full-time work. It is quite a task to help an insurer know that there are “good days” and “bad days” with many illnesses. Declarations can be extremely useful to provide accounts of symptoms, but insurers tend to dismiss or ignore these probative statements altogether, relying almost exclusively on the medical records reviewers they hire, who have never even met the claimant. One court recently acknowledged the importance of declarations and letters from colleagues and friends, noting that although they “are not medical professionals and do not have the medical training necessary to provide a medical opinion regarding Laurie’s functional capacity, they are arguably in the best position to substantiate Laurie’s subjective complaints. United should not have dismissed them without discussion, and it was an abuse of discretion to do so.” Laurie v. United of Omaha Life Ins. Co., 2017 WL 975947, at *20 (D. Or. Jan. 23, 2017), report and recommendation adopted, 2017 WL 970262 (D. Or. Mar. 13, 2017).
GMA’s interviewer, Robin Roberts, reports that even Ms. Blair’s own doctors did not take her complaints seriously prior to her diagnosis, but attributed her complaints of pain and exhaustion to being a single mother or hormones. She asked for an MRI, but doctors dismissed her request as unnecessary. Yet her exhaustion was overwhelming: “I’d drop my son off at school a mile away and before I got home I’d have to pull over and take a nap.” But Ms. Blair told her doctors “I need to go to work, and I have to stay awake.” After years of symptoms, it finally took Ms. Blair falling in front of a doctor before she received her diagnosis. Ms. Blair has continued working as an actor all these years, noting “I’m still an actress! Mama’s still got to bring home the bacon, people! I’m a single mom!”
Ms. Blair’s narrative aligns with the experience of many of my clients: they fight through symptoms to keep working, fight to get a diagnosis, then fight with an insurance company to receive benefits. It is overwhelming and exhausting. And it is my privilege to take on the insurance companies on my clients’ behalf.
Read MorePresenting @ the ACCTLA sponsored event!
I will be speaking on a panel that presents the topic: Navigating Disability in the Workplace hosted by the @ALAMEDA-CONTRA COSTA TRIAL LAWYERS ASSOCIATION on Wednesday, May 15th. I look forward to the discussions, questions, and interactions.
For more regarding this event, contact me @ Cassie Springer Ayeni, President of Springer Ayeni, A Professional Law Corporation @www.benefitslaw.com
Or visit: https://lnkd.in/gk8nC2D
Read MoreERISA Administrative Claims and Litigation on June 6 in DC!
Getting excited to speak on ERISA Administrative Claims and Litigation on June 6 in DC! Should be a great panel, with Robert Rachall and Yolanda Montgomery. Join us if you can! https://lnkd.in/gH6h5_d For more regarding this event, contact me Cassie Springer Ayeni, President of Springer Ayeni, A Professional Law Corporation @www.benefitslaw.comhashtag#Employeedisabilitybenefitshashtag#ERISAdisablityhashtag#ERISAlawyerhashtag#Superlawyerhashtag#Disabilityclaimshashtag#Disabilityappealshashtag#Longtermdisabilityhashtag#ERISAlitigatorhashtag#ERISAbayareahashtag#Disabilitylawyerhashtag#Employeebenefitslawyerhashtag#ERISAlawfirmhashtag#benefitslawhashtag#Springerayenihashtag#ABAhashtag#EBChashtag#erisa
Read MorePresenting at San Francisco Trial Lawyers Association
On Tuesday November 20th, I will be on a panel discussing the topic “Negotiating Tactics” at the San Francisco Trial Lawyers Association. What better way to navigate the Thanksgiving table than by attending this Negotiations CLE!
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