If you get health insurance through your employer, your plan is likely governed by the Employee Retirement Income Security Act (ERISA). This federal law provides specific appeal rights that your insurer must follow — knowing them gives you significant leverage.
What Is ERISA?
ERISA is a federal law that governs most employer-sponsored health plans. It sets minimum standards for:
- How claims must be processed
- Your right to appeal denials
- Required disclosures and notices
- Timeline the insurer must follow
Important: ERISA applies to employer plans but NOT to individual marketplace plans, government plans (Medicare, Medicaid, TRICARE), or church plans.
Your ERISA Appeal Rights
First-Level Internal Appeal
- You have 180 days from the denial notice to file
- The insurer must use a different reviewer than the one who made the initial denial
- You must be given access to your complete claim file
- The insurer must provide the clinical rationale for the denial
Second-Level Internal Appeal
- Required for most ERISA plans before external review
- Same 180-day deadline from the first appeal denial
- Must be reviewed by a different reviewer
Post-Appeal Options
After exhausting internal appeals:
- External review (independent third party)
- Federal court action under ERISA Section 502(a)
- State insurance commissioner complaint (limited for ERISA plans)
Key ERISA Protections
- Full and fair review — the insurer must give you a full opportunity to present your case
- Document access — you can request and receive all documents relevant to your claim
- New evidence — the insurer must consider new evidence submitted during the appeal
- Qualified reviewers — medical decisions must be reviewed by someone with appropriate expertise
- No deference — the external reviewer gives no deference to the insurer's prior denial
ERISA Deadlines for Insurers
| Claim Type | Decision Deadline |
|---|
| Urgent care | 72 hours |
| Pre-service | 30 days |
| Post-service | 60 days |
| Disability | 45 days |