What Is ERISA?
ERISA (Employee Retirement Income Security Act) is federal law governing employer-sponsored health insurance plans. ERISA establishes minimum standards for plan administration, requires disclosure of plan information, and guarantees appeal rights for benefit denials. If your health insurance is through an employer (rather than purchased individually), your plan is likely governed by ERISA.
ERISA provides important protections: plans must have clear claim procedures, explicit appeal processes, and timelines for claims processing. ERISA also allows you to sue for benefits if denied inappropriately.
ERISA-Protected Appeal Rights
ERISA guarantees: the right to know your coverage terms and plan documents, the right to file a claim for benefits, the right to appeal adverse determinations (denials), timelines for appeals (usually 30-60 days), and the right to request external review for certain denials. Plans must provide written notice of adverse determinations explaining the reason and your appeal rights.
ERISA appeals are different from state insurance appeals. ERISA plans may have different timelines and procedures than regulated insurance plans.
ERISA Claim and Appeal Process
File a claim for benefits according to your plan's process (usually through your employer's benefits administrator). If denied, the denial notice must explain the reason, reference plan language supporting the denial, and explain your appeal rights. You have 180 days to appeal.
Submit your appeal in writing to the plan administrator or plan's appeals department. Include the denial notice, supporting documentation, and explanation of why you believe the denial was wrong.
External Review Rights Under ERISA
For certain denials (based on medical necessity, treatment appropriateness), you have the right to external review. Some external reviews are conducted by independent review entities affiliated with your plan. You can also request expedited external review if your condition requires urgent treatment.
Legal Rights Under ERISA
If your ERISA plan wrongfully denies benefits, you can sue the plan for the benefits plus attorney fees and court costs (if successful). This makes ERISA violations costly for plans and provides strong incentive for correct claim handling. Having legal representation significantly improves your chances in ERISA litigation.