The Complete ERISA Appeal Process Explained

ERISA Appeal Requirements

The Employee Retirement Income Security Act (ERISA) establishes minimum standards for employer health plan appeals:

Mandatory Internal Review

• One full and fair internal review is required
• Must use different reviewer than original decision-maker
• Reviewer must be qualified (appropriate expertise)
• Decision within 30 days (pre-service), 60 days (post-service), 72 hours (urgent)

Your Rights Under ERISA

1. Right to all documents used in the denial decision — request your full claim file
2. Right to submit new evidence during the appeal
3. Right to know reviewer qualifications — who reviewed your case and their credentials
4. Right to specific denial explanation — reason, policy provisions, and clinical rationale
5. Right to file suit in federal court after exhausting administrative remedies

Administrative Exhaustion

You typically MUST complete internal appeals before filing a lawsuit. However, exceptions exist:

• Plan fails to meet ERISA timelines
• Appeal would be futile (plan has already decided)
• Plan did not follow its own procedures

Federal Court

After exhausting ERISA appeals, you can file suit in federal court:

• Standard of review: usually "abuse of discretion" (plan is given deference)
• Limitations: generally limited to what was in the administrative record
• Remedies: typically limited to the denied benefit (no punitive damages)
• Consult an ERISA attorney before filing

Key Tips

• Build your administrative record carefully — it's what the court will review
• Submit all relevant evidence during the internal appeal — you may not be able to add it later
• ERISA timelines are strict — don't miss deadlines