If you have employer-sponsored health insurance, your plan is likely governed by ERISA (Employee Retirement Income Security Act). ERISA appeals have specific rules and deadlines that differ from individual insurance plans.
What Is ERISA?
ERISA is a federal law that governs most employer-sponsored benefit plans. It:
- Preempts most state insurance regulations
- Sets minimum standards for appeals processes
- Limits remedies in lawsuits (generally only denied benefits, not punitive damages)
- Requires plan administrators to provide specific information
ERISA Appeal Requirements
Mandatory Internal Appeal
- File within 180 days of the denial
- The plan must provide a "full and fair review"
- Reviewer must be different from the initial decision-maker
- You have the right to submit additional evidence
- Decision within 30 days (pre-service) or 60 days (post-service)
What the Plan Must Provide You
- Specific reasons for the denial
- Reference to plan provisions used
- Description of additional materials needed
- Description of the plan's review procedures
- For medical necessity denials: the clinical rationale
Building the Administrative Record
Critical concept: In most ERISA cases, if you go to court, the judge only reviews what was in the "administrative record" — meaning what you submitted during the appeal. You generally cannot introduce new evidence in court.
This means you must submit EVERYTHING during the internal appeal:
- All medical records
- All expert opinions
- All clinical guidelines and literature
- All plan documents and communications
- Any independent evaluations
After Internal Appeal Is Exhausted
- You may file a lawsuit in federal court
- Generally limited to recovery of denied benefits
- Punitive damages usually not available under ERISA
- Court reviews the plan administrator's decision (often deferential)
- Some courts allow "de novo" review in certain circumstances