How to Appeal a Denial from Your Employer's Health Plan

Understanding Your Employer Plan

Fully-Insured Plans

• Employer buys coverage from an insurance company
• Regulated by state insurance department
• Subject to state consumer protection laws
• External review available through state programs

Self-Insured (Self-Funded) Plans

• Employer pays claims directly (insurer just administers)
• Regulated by federal DOL under ERISA
• NOT subject to most state insurance laws
• External review may be limited

ERISA Appeal Requirements

1. Internal appeal — file within 180 days of denial
2. Plan must decide within 30 days (pre-service) or 60 days (post-service)
3. Full and fair review — must use different reviewer than original decision
4. You can submit new evidence during the appeal
5. If denied — you may file suit in federal court

How to Determine Your Plan Type

• Check your Summary Plan Description (SPD)
• Ask HR whether the plan is self-insured or fully-insured
• Self-insured plans often say "administered by" rather than "insured by"
• Your plan documents should specify which entity bears the financial risk

Key ERISA Protections

• Right to all documents used in the denial decision
• Right to know the qualifications of the reviewer
• Right to a clear explanation of the denial reason
• Right to file suit if administrative remedies are exhausted