The Employee Retirement Income Security Act of 1974 (ERISA) governs most employer-sponsored benefit plans in the United States, including long-term disability (LTD), short-term disability (STD), life insurance, and pension benefits. When an insurance company denies or terminates your claim under an ERISA-governed plan, the administrative appeal is your one and only chance to build the record that a federal court will later review. Miss the deadline or submit weak evidence, and your case may be barred forever.
This comprehensive guide walks you through the ERISA appeal process step by step. We’ll cover deadlines, evidence, templates, and common insurer tactics—backed by federal regulations and court rulings. By the end, you’ll know exactly what to do (and when) to maximize your chances of overturning a wrongful denial.
Step 1: Read Your Denial Letter Like a Lawyer (Checklist)
Your denial letter is the starting gun for the appeal clock. Under federal regulations at 29 CFR § 2560.503-1, the insurer must provide specific reasons for the denial (not vague statements like “insufficient medical evidence”), reference to the exact plan provision relied upon, a description of additional material needed to perfect the claim, and your appeal rights, including the exact deadline (usually 180 days from the date of the letter).
If the letter is incomplete, you may later argue a procedural violation under the U.S. Supreme Court’s ruling in Montanile v. Board of Trustees (577 U.S. 136, 2016). Save the envelope—postmark dates matter.
Denial Letter Checklist:
- Is a specific reason cited?
- Is plan language quoted?
- Is the 180-day appeal deadline stated?
- Is the internal appeal procedure described?
- Is your right to request documents mentioned?
Step 2: Beat the 180-Day Clock
The 180-day appeal window is non-negotiable in most plans. As ruled by the U.S. Supreme Court in Heimeshoff v. Hartford Life (571 U.S. 99, 2013), the clock starts when you receive the denial letter—not when it’s mailed.
To calculate your deadline:
- Note the date printed on the denial letter.
- Add 180 calendar days.
- Submit your appeal at least 5–7 days early via certified mail to account for delivery.
Some plans allow only 60 days for health claims or 45 days for urgent care. Always check your Summary Plan Description (SPD) to confirm.
Step 3: Gather Bulletproof Evidence (Medical + Vocational)
Under ERISA, you cannot introduce new evidence in court after the administrative record closes, as established in Perry v. Simplicity Engineering (900 F.2d 963, 6th Cir. 1990). This makes your appeal evidence make-or-break.
Medical Evidence Checklist
- Treating physician narrative: A detailed letter from your doctor explaining your functional limitations and why you cannot perform your job duties.
- Functional Capacity Evaluation (FCE): An objective assessment by a physical or occupational therapist measuring your physical restrictions.
- Neuropsychological testing: Critical for cognitive or mental health claims to document memory, concentration, or processing deficits.
- Daily activity logs: Dated entries showing how your condition affects routine tasks—especially useful to counter insurer surveillance.
Vocational Evidence
Include a vocational expert report that identifies:
- Your job’s Dictionary of Occupational Titles (DOT) code
- How your medical restrictions prevent you from performing that occupation
- Labor market data (required if claiming “any occupation” disability after 24 months)
Step 4: Write the Appeal Letter (Free Template)
Your appeal must be in writing and sent via certified mail with return receipt requested. Use this proven structure:
[Your Name] [Your Address] [City, State, ZIP] [Date]
[Plan Administrator Name] [Insurance Company Name] [Address] [City, State, ZIP]
RE: Appeal of Claim Denial – Policy #XXXXX, Claimant: [Your Name], Date of Denial: [Date]
Dear Plan Administrator,
I am appealing the denial of my long-term disability benefits dated [date of denial letter]. The denial violates ERISA regulations for the following reasons:
- Incomplete Review – The insurer failed to consider my treating physician’s report dated [date], which documents [specific limitation].
- Misapplication of Plan Terms – The definition of “disability” was incorrectly applied under [plan page X, quote exact language].
- Procedural Violations – The denial letter omitted required disclosures under 29 CFR § 2560.503-1(h)(2)(iv).
Enclosed Evidence:
- Updated medical records from [doctor/hospital] (45 pages)
- Vocational expert report by [expert name] (15 pages)
- Daily activity logs (January–June 2026)
I request a full and fair review by a new claims examiner not involved in the initial denial. Please provide all plan documents, including the full insurance policy and administrative services agreement, within 30 days as required by ERISA § 104(b)(4).
Sincerely, [Your Signature] [Your Printed Name] [Phone] | [Email]
Step 5: What Happens After You Submit?
After submission, the insurer typically has 45 days to decide (90 days with one 45-day extension for special circumstances). You’ll receive a written decision. If upheld, you may file a federal lawsuit. If overturned, benefits are restored with interest.
Key Court Standards:
- Firestone Tire & Rubber Co. v. Bruch (489 U.S. 101, 1989): Courts apply de novo review unless the plan grants the insurer discretion.
- Black & Decker Disability Plan v. Nord (538 U.S. 822, 2003): Insurers are not required to give special weight to treating physicians—but must explain why they disagree.
ERISA Appeal FAQs
What happens if I miss the 180-day appeal deadline? You are generally barred from suing in federal court. The administrative record closes, and courts enforce plan deadlines strictly (Heimeshoff v. Hartford, 2013).
Can I hire a lawyer after the appeal is denied? Yes, but the appeal record is frozen. An experienced ERISA attorney should handle the appeal to preserve your strongest case from the start.
Do I need a vocational expert? Not always for “own occupation” claims, but essential after 24 months when the definition shifts to “any occupation.” Courts often criticize insurers for ignoring vocational evidence.
Final Thoughts: Don’t Go It Alone
The ERISA appeals process is riddled with procedural traps designed to protect insurers, not claimants. A single missed deadline or incomplete medical record can cost you tens or hundreds of thousands in benefits.
That’s why thousands of claimants nationwide trust specialized ERISA attorneys to handle the heavy lifting—from dissecting denial letters to negotiating six-figure settlements.
Overwhelmed by the paperwork? Our team at Eric Buchanan & Associates reviews appeals for free. Upload your denial letter today and get a clear path forward. (Visit our website)
