The Employee Retirement Income Security Act (ERISA) governs most employer-sponsored health plans. ERISA provides specific appeal rights but also limits some remedies. Understanding these rules is critical if you have insurance through your employer.
What Is ERISA?
ERISA is a federal law that:
- Governs most employer-sponsored benefit plans (excluding government and church plans)
- Preempts (overrides) most state insurance laws for covered plans
- Provides specific appeal procedures and rights
- Limits remedies in court (no punitive damages)
ERISA Appeal Process
Internal Appeal
- Pre-service urgent: Plan must decide within 72 hours
- Pre-service non-urgent: 30 days (extendable by 15 days)
- Post-service: 60 days (extendable by 30 days)
- You have 180 days to file an appeal
External Review
- Available for medical judgment and rescission claims
- Must exhaust internal appeals first (or plan failed to follow procedures)
- Independent reviewer decision is binding
ERISA-Specific Rules
- Full and fair review: You have the right to review your complete claim file
- Treating physician deference: While not binding, your doctor's opinion must be considered
- New evidence at appeal: You can submit evidence not in the original claim
- Administrative record: If you go to court, the judge typically reviews only what was in the administrative record — make your appeal record as strong as possible
- Exhaustion requirement: Must exhaust plan appeals before filing federal lawsuit (usually)
Why ERISA Matters
- State consumer protection laws often don't apply to ERISA plans
- Lawsuits are limited to recovering the denied benefits (no punitive damages)
- This makes a thorough administrative appeal even more important
- The appeal record becomes the court record if litigation follows
When to Get Legal Help
Consider consulting an ERISA attorney if:
- High-value claim (surgery, ongoing treatment)
- Multiple appeal levels exhausted
- Suspected bad faith or procedural violations
- Complex disability or long-term care claims