How to File a Winning ERISA Claim

If you have an employment-related benefit claim, ERISA likely applies to your claim.  ERISA claims involve complex rules and strict deadlines that can be challenging and challenging to navigate. Understanding the process can significantly improve your chances of success. This guide outlines how to file a claim, respond to a denial, and improve your chances of winning an ERISA claim or ERISA appeal.

What Is ERISA?

 The place to start is to explain what ERISA is. ERISA is an acronym for the Employee Retirement Income Security Act, a law passed by Congress in 1974 aimed at protecting the rights of employees who participate in their employers’ benefit plans and their dependent beneficiaries. ERISA applies to a wide range of employee benefits – pensions, 401(k) and 403(b) plans (non-government employees), disability, health, and life insurance benefits, along with severance and other benefits administered by employers.

ERISA’s scope only encompasses the private sector, though. State, federal, or municipal employees are excluded except where they have union-sponsored benefits.  Another significant exemption is “church plans,” which are benefits sponsored by religious organizations.

What Is an ERISA Claim?

 Just about any type of claim for benefits brought under a private sector or union sponsored employee benefit program is considered an ERISA claim.

How Can I Determine My Rights to Bring an ERISA Claim?

 Federal law requires that employers provide employees with a summary plan description of their benefit programs. By law, the summary description must include information about claims and how to go about submitting a claim for benefits, deadlines for submitting claims, and claim appeals.

How Do I File an ERISA Claim?

Different types of claims may utilize different claim procedures. To the extent an employee is uncertain as to their rights after reviewing the summary plan description for the benefit at issue, human resources personnel should be able to explain the process.

Here are some specifics as to different types of claims:

Retirement Benefits

Depending on the nature of the retirement benefits claim (i.e., pension or 401k), employees need to complete a set of forms specifying how and to whom benefits are to be paid. The election is usually irrevocable. So, the employee should understand and make sure they are making the correct election. The employee may need assistance from a financial advisor.  If the employee is married and seeks a lump sum benefit distribution, he or she must submit a notarized written spousal consent.

Disability

There are three parts to every disability insurance benefits claim that must be completed and submitted – the employee’s statement, the employer’s statement, and the attending physician’s statement. The employee’s statement describes the nature of the disabling impairment and how it affects the employee’s ability to work. The employer’s statement provides information about the employee’s work duties, when the employee ceased working, and the employee’s rate of pay.  Finally, the attending physician’s statement explains the nature of the employee’s medical condition and offers other medical information that is used to determine disability.

A claimant should submit the forms as soon as possible after the onset of disability. However, a claim should not be started until the employee knows their treating doctor will support their claim.

Health Benefits

Most health insurance benefits claims are routine and are submitted directly by the doctor or hospital to the insurer or plan administrator.  However, claims that require pre-approval or claims involving newly developed drugs or treatments, and many types of behavioral health treatment, may require a letter of medical necessity from the treating doctor before the claim is approved.  Claimants should be sure that their physicians are ready and willing to back up their claims.  With certain pharmaceuticals and medical devices, the manufacturer may also be able to provide helpful resources.

Life Insurance or Accidental Death Insurance

In most instances, all that is necessary to complete an application for life insurance benefits is proof of beneficiary designation, a copy of the official death certificate, and completion of a form.  The form needs to  list the name, address, and other demographic information from the beneficiary claimant. However, if an autopsy was performed, it can be useful to have a copy of the report if available prior to submitting a life insurance claim. In accidental death benefits claims where there was law enforcement involvement, such as a fatal car accident, it would be advisable to obtain a copy of the police report and submit it with the claim.

What Happens After the Claim Is Submitted?

 The Insurance company or designated benefits personnel will be review. Depending on the nature of the claim, the insurer or plan administrator is required to process the claim within deadlines imposed by the U.S. Department of Labor for rendering a claim decision. Delays may occur if the insurer or benefit administrator needs to gather additional evidence such as medical records, police reports, and medical examiner/coroner evidence.

What Happens if the Claim Is Denied?

If the insurer denies your claim, as a claimant, you have the right to a “full and fair review” of the claim denial. That means the participant or beneficiary has the right to appeal the denial and in fact are usually obligated to do so as a prerequisite to seeking court intervention.  Many types of claims have very short time deadlines for appeals such as health insurance claims classified as “urgent,” i.e., where the patient’s life is in jeopardy, or the patient is in severe pain.  Appeal deadlines in such matters can be as short as three days.

Understanding the ERISA Appeals Timeline

ERISA claim appeals are often complex because they may involve medical judgments or legal interpretations.  A comprehensive set of regulations issued by U.S. Department of Labor outlines the requirements for appeals, including deadlines imposed both on claimants and on the insurer or plan administrator. Those regulations are intended to ensure the appeal process is fair to the claimant and not just a rubber stamp.

ERISA appeals involve legal proceedings that often require an attorney’s help. Claimants need assistance to navigate the complex ERISA appeal process. A knowledgeable ERISA attorney will analyze adverse evidence, gather necessary additional evidence, and present winning arguments to overturn unjustified denials. Early attorney involvement is crucial because if your appeal fails, courts may not consider new evidence later. Waiting until after a denial to hire an attorney could prevent you from recovering benefits..

Building a Strong Appeal

1. Request Your Claim File: Under ERISA, you have the right to review all documents the insurer used in their denial decision.
2. Obtain Additional Medical Evidence: If possible, get updated physician statements or functional capacity evaluations.
3. Address the Insurer’s Reasons for Denial: Carefully counter any arguments used against your claim.
4. Consult an ERISA Attorney: Legal guidance can improve your chances of success.

You must strictly meet all appeal deadlines. If you submit your appeal even one day late, you could lose benefits and forfeit your right to challenge the decision in court.

Related Article: Common Mistakes When Appealing a Denial of Long Term Disability Benefits

After you submit your appeal, the insurer may take up to 90 days to decide whether they approve or deny it. For disability claims, if the insurer or benefit administrator finds evidence during the appeal that contradicts your claim, they must share this evidence with you and give you an opportunity to respond before they make their final decision..

What if the Appeal Is Denied?

If the appeal is denied, the next step in the process is to bring a lawsuit.

Court Jurisdiction and Trial Process

Because ERISA is a federal law, most ERISA benefit cases are heard in federal court. However, state courts may also have jurisdiction if both parties agree to keep the case there. Court rulings have determined that jury trials are not available in ERISA cases. ERISA litigation also differs from other types of lawsuits in key procedural ways.

Limitations in ERISA Litigation

Most courts impose strict limits on “discovery” in ERISA cases, restricting depositions and other forms of fact-gathering that typically occur in civil lawsuits. Instead, courts typically review only the evidence submitted during the claim and appeal process. As a result, verdicts are typically based exclusively on the administrative record and legal submissions from both parties, with no live witness testimony.

The Standard of Review in ERISA Cases

One of the complexities of ERISA litigation is that even if a court finds an insurer’s decision incorrect, the claimant may still lose the case. This happens when the court applies the “abuse of discretion” or “arbitrary and capricious” standard, which requires the claimant to prove the insurer’s decision was not just incorrect, but unreasonable. Whether this standard applies depends on the language in the insurance policy. If the policy grants the insurer or plan administrator “discretion” in decision-making, courts typically defer to the insurer’s judgment. This makes it especially important for claimants to be represented by attorneys experienced in ERISA litigation, who can develop the strongest possible arguments to counter these legal hurdles.

Potential Outcomes of ERISA Litigation

If litigation is successful, courts may, but are not required to, award attorneys’ fees and prejudgment interest in addition to accrued benefits.

If litigation is successful, courts may, but are not required to, award attorneys’ fees and prejudgment interest in addition to accrued benefits. However, fees are not recoverable at the claim appeal stage.

How to Strengthen an ERISA Appeal

• Obtain additional medical evidence: If the denial cited insufficient proof, consider adding a functional capacity evaluation (FCE) or vocational assessment.
• Address policy interpretations: If the insurer relied on ambiguous policy language, counter it with legal arguments.
• Challenge insurer’s medical review: If the insurer used an independent medical examiner (IME), obtain a rebuttal from your treating physician.
• Ensure procedural compliance: ERISA requires insurers to follow specific claims processing regulations. Identifying violations can strengthen your appeal.

How to Avoid Common ERISA Claim Mistakes and Strengthen Your Case

Filing an ERISA claim requires attention to detail, proper documentation, and strict adherence to deadlines. Many claimants unknowingly make errors that weaken their cases. Below are the most critical steps to take and pitfalls to avoid ensuring the strongest possible claim.

Request Your Plan Documents and Understand Your Rights

Before filing, obtain a copy of your Summary Plan Description (SPD), policy documents, and claims procedures. These documents outline your benefits, filing deadlines, and what evidence is required.

Meet All Deadlines:  Even a One-Day Delay Can Cost You Benefits

ERISA has strict deadlines for filing claims and appeals. Health-related claims marked as “urgent” may have response deadlines as short as 72 hours. Disability and life insurance appeals generally must be filed within 180 days. A missed deadline can permanently bar your claim.

Ensure Your Doctor Supports Your Claim and Documents it Clearly

One of the biggest reasons for claim denials is a lack of strong medical evidence. Insurers often argue that treating physicians failed to provide needed information. Below is a of what you need from your treating doctors:

• Objective test results supporting disability (MRI, X-ray, lab work, etc.).
• Clear statements regarding why the claimant cannot work, not just a diagnosis.
• Medical opinions that address specific job-related functional limitations.

Don’t Rely on Verbal Promises or Informal Communications

Insurance representatives may verbally suggest they will cover a claim, approve a treatment, or allow an extension—but if it’s not in writing, it doesn’t exist under ERISA. Keep copies of every communication, including emails and letters, and submit all evidence in writing.

Watch out for Surveillance and Social Media Pitfalls

Insurers frequently use video surveillance, social media monitoring, and online searches to find evidence that contradicts disability claims. A brief social media post or even casual outdoor activity can be misrepresented as proof of ability to work.

Don’t Appeal Without Strengthening Your Case

Simply resubmitting the same claim with a letter stating “I disagree” is not enough. An appeal should correct deficiencies in the original claim, such as:

• Providing additional medical records or physician statements.
• Obtaining a vocational expert’s evaluation of your ability to work.
• Addressing insurer arguments with new supporting evidence.

Consider Legal Assistance Early

Many ERISA claimants wait until after a final denial to seek legal help, which can be a mistake. Courts rarely allow new evidence once a case moves to litigation. Working with an ERISA attorney during the appeal stage can increase the chances of success before going to court.

Final Thoughts

ERISA claims involve strict deadlines and complex legal standards. Successfully challenging a denial requires thorough preparation and strong supporting evidence. If your claim has been denied or if you need guidance before filing, working with an experienced ERISA attorney can make the difference. Contact DeBofsky Law to discuss your case and protect your benefits.

Frequently Asked Questions About Winning ERISA Claims

What should I do if the insurance company keeps requesting more information?

Insurance companies may sometimes delay claims by continuously requesting additional documentation and may even request information again that has already been submitted.  If that occurs, politely comply but firmly emphasize that the documentation was previously submitted and attach evidence of transmittal.  Claimants should also firmly request that they receive a timely determination in accordance with the deadlines set forth in the U.S. Department of Labor’s ERISA Claim Regulations.

How does an ERISA appeal differ from a new claim submission?

An ERISA appeal is not just a resubmission of the same claim. It is a legal challenge that must specifically address the reasons for denial and provide additional evidence in support of the clam. If the denial was based on a policy interpretation, the appeal must counter it with legal arguments. Importantly, the appeal is often the final opportunity to introduce new evidence.  If the case later goes to court, the judge typically only considers what was submitted during the appeal.

Does my employer control my ERISA benefits, or does the insurance company?

It depends on how the plan is structured. If the plan is fully insured, the insurance company both administers the claims and pays benefits, meaning the employer has no financial stake in approvals or denials. However, if the plan is self-funded, the employer directly pays claims, which can create a financial conflict of interest. In self-funded plans, even if an insurance company administers the claims, the employer has the final say in approving or denying benefits.

How can I prove that my disability prevents me from working?

Medical records alone are often not enough to win an ERISA disability claim. Insurers frequently argue that claimants can still perform sedentary work. To counter this, claimants may need to obtain:

• A Functional Capacity Evaluation (FCE) to objectively measure physical limitations.
• A vocational expert opinion explaining why the claimant’s restrictions prevent them from performing past work or alternative jobs.
• Consistent medical documentation demonstrating ongoing functional impairments, rather than just a diagnosis.

Can my benefits still be terminated after winning an appeal?

Yes. Winning an ERISA appeal does not guarantee future payment of benefits indefinitely. Insurers frequently monitor claimants for potential termination by:

• Requiring updated medical reviews or independent medical exams.
• Conducting video surveillance to dispute physical limitations.
• Examining social media to see if any postings contradict claimed limitations
• Claiming medical improvement based on minor inconsistencies in doctor reports.

What if my claim is delayed instead of denied?

Insurance companies sometimes delay claims instead of outright denying them. ERISA regulations require claims to be decided within specific timeframes, but insurers may request excessive information, repeatedly ask for documents already submitted, or take other steps to stall the process. These tactics can be frustrating and may financially harm claimants.

• You have the right to demand a timely decision under ERISA rules.
• If delays persist, you may need to escalate your case or consider legal action.
• Learn more about when you can sue for delays.

To protect against termination, claimants should continue medical treatment, keep detailed records of symptoms, and document any work-related restrictions over time.