Can I appeal an ERISA claim denial?

On Behalf of | Sep 28, 2023 | Erisa & Employee Benefits |

When facing the denial of an Employee Retirement Income Security Act claim, individuals often wonder about their options for appeal.

ERISA governs employee benefit plans offered by employers, encompassing health insurance, disability benefits and retirement savings. To navigate this process effectively, it is important to know the steps to take.

1. Examine the denial letter

The first step involves comprehending the reasons behind the denial. ERISA mandates that plan administrators provide written explanations for claim denials. Analyze this letter carefully to identify the specific issues or information that led to the denial.

2. Gather supporting documentation

Assemble all relevant documents and medical records that substantiate your eligibility for the benefits in question. These documents may include medical reports, test results and any other proof of the severity of your condition or need for the benefits.

3. Refer to the Summary Plan Description

Consult your plan’s SPD to understand the processes and deadlines for appealing a denial. ERISA mandates that you exhaust all administrative remedies before considering legal action. Therefore, closely adhere to the guidelines outlined in the SPD.

4. Draft a persuasive appeal letter

Compose a well-structured appeal letter that directly addresses the issues raised in the denial letter. Ensure that you include all necessary information and documents, presenting your case clearly and persuasively. Avoid vague or ambiguous language to prevent misinterpretation.

5. Submit it on time

Submit your appeal within the timeframe specified in your plan’s SPD. Meeting these deadlines preserves your right to challenge the denial. Sending the appeal via certified mail with a return receipt provides proof of submission, adding an extra layer of security.

Every year, approximately 2.5 million ERISA-covered group health plans cover 136 million participants and beneficiaries. When a denial happens, the appeal process takes time but is an option worth considering.