Violations in Claim Handling: How “Full and Fair Review” Can Save Your Life Insurance Claim
When a loved one dies, the last thing your family expects is a denied life insurance claim—especially when the policy was provided through their employer. Many of these claims are governed by a federal law called ERISA (the Employee Retirement Income Security Act), which sets strict rules for how insurance companies and plan administrators must handle claims and appeals.
Recently, courts have been calling out insurers for ERISA procedural violations—in other words, for breaking the rules about how they handle your claim, not just whether they got the medical or legal issues right. In one widely discussed case, Black v. Unum Life Insurance Company of America, the court found that the insurer failed to give the claimant a “full and fair review” as ERISA requires, and sent the case back to the insurer to redo the review correctly.
If your employer-provided life insurance claim has been denied, these same ERISA rules may give you powerful leverage to challenge the denial—especially with an experienced life insurance lawyer guiding you.
What Does ERISA Require? “Full and Fair Review” in Plain English
Under ERISA § 503 and the Department of Labor’s regulations, every ERISA plan must have a claims process that gives you:
Clear written notice of why your claim was denied; and
A reasonable chance to appeal that denial and get a “full and fair review” by the plan’s fiduciary.
The regulations spell out what a “full and fair review” must include. Among other things, the plan must:
Give you enough time to appeal (at least 60 days for many ERISA plans; often longer for health and disability).
Allow you to review the claim file and any new evidence the insurer is relying on.
Let you submit additional documents, medical records, and arguments on appeal.
Use reviewers with appropriate training and experience for medical or technical issues.
Avoid giving undue deference to the initial denial when deciding the appeal.
When insurers cut corners on these steps, they may be violating ERISA—even if they insist they “followed the policy.”
Black v. Unum: A Real-World Example of ERISA Procedural Violations
Although Black v. Unum involved long-term disability benefits, the court’s reasoning is important for any ERISA-governed benefit, including employer-provided life insurance and accidental death (AD&D) claims.
In Black, the plaintiff had received disability benefits for years before Unum terminated them. On appeal, Unum leaned heavily on a nurse reviewer to uphold its decision. The court found several problems:
The nurse was not a physician, and there was no evidence she had the “appropriate training and experience” in the medical field at issue, as ERISA regulations require for medical judgments.
Unum appeared to defer to its original decision, instead of giving a fresh, independent look on appeal.
The process as a whole did not meet ERISA’s minimum standards for a full and fair review.
The court held that Unum failed to provide a full and fair review and remanded the case back to the insurer to conduct a proper review consistent with ERISA’s procedural requirements.
Why does that matter to you as a life insurance beneficiary?
Because similar procedural violations happen in group life and AD&D claims all the time. If the insurer mishandles the process, the court can:
Send the case back to the insurer for a proper review (a remand), or
In some situations, change the standard of review or weigh the insurer’s decision less favorably if the violations are serious.
Either way, procedural errors can create leverage that a skilled life insurance attorney can use to fight for your benefits.
Common ERISA Procedural Violations in Life Insurance Claim Handling
Here are some red flags we look for when reviewing a denied ERISA life insurance claim:
1. Missing or Vague Denial Letters
ERISA requires denial letters to be specific—they must explain:
The exact reason for the denial
The plan provisions the insurer is relying on
What additional information is needed to perfect the claim
A description of your appeal rights and deadlines
If your letter just says something like “benefits are not payable under the terms of the policy” without details, that may not be enough under ERISA.
2. Failure to Share the Claim File and New Evidence
On appeal, you’re entitled to a reasonable opportunity to review and obtain relevant documents in your claim file—medical reviews, internal notes, vocational reports, and more.
Procedural problems arise when:
The insurer refuses to give the claim file,
Only sends partial documents, or
Introduces new evidence on appeal without giving you a chance to respond.
3. Using the Wrong Kind of Reviewer
In Black v. Unum, the court emphasized that ERISA requires reviewers with appropriate training and experience in the relevant medical field when the denial is based on medical judgment.
In the life insurance context, similar issues can arise when:
A complex cause-of-death question (cardiac vs. pulmonary, toxicology, accident vs. illness) is reviewed by someone without proper medical expertise;
A generalist reviewer dismisses a specialist’s opinion (e.g., cardiologist, oncologist) without meaningful explanation;
The insurer relies on paper reviews that ignore key evidence from treating physicians or the death certificate.
4. Rubber-Stamping the Original Denial
ERISA regulations emphasize that the appeal must be a fresh, independent review, not a rubber stamp of the original decision.
Red flags include:
The same person who made the initial decision handling the appeal;
Appeal letters that look like copy-and-paste versions of the original denial;
No real engagement with new evidence you submitted.
5. Blowing Deadlines or Keeping You in “Limbo”
ERISA sets strict time limits for insurers to decide claims and appeals. When administrators miss deadlines, fail to update you, or drag things out indefinitely, courts may treat the claim as deemed denied or may apply a less deferential standard of review.
If your loved one died months—sometimes years—ago and your life insurance claim is still “under review”, you may be facing an ERISA procedural violation.
How ERISA Procedural Violations Can Help Your Case
Procedural violations do not automatically mean you win your case, but they can change the playing field in important ways:
The court may remand the case to the insurer for a proper review, forcing them to seriously reconsider the claim.
Serious or repeated violations can lead courts to review the denial more strictly (de novo) rather than giving the insurer’s decision deference.
Courts may view procedural problems as evidence of bias or bad faith, especially when the insurer both decides and pays claims, which is common with employer-provided life insurance.
An experienced ERISA life insurance lawyer will dig into the claim file, internal notes, and timeline to identify every violation and use them to strengthen your case.
Example: How This Plays Out for a Life Insurance Beneficiary
Imagine this scenario:
Your spouse had employer-provided life insurance through their job.
After their death, you submit a claim. Months later, the insurer denies benefits, saying the policy “lapsed” or that your spouse was “not eligible” for coverage.
You appeal, sending payroll records showing premiums were deducted and HR documents showing coverage elections.
On appeal, the insurer never shares its internal communications, fails to address your evidence, and has the same person who issued the first denial sign off again with a copy-and-paste letter.
Even if the insurer insists it is “right on the law,” these procedural failures may violate ERISA—and that can give you a strong argument in federal court.
What You Should Do If Your ERISA Life Insurance Claim Is Denied
If your group life or AD&D claim has been denied or stuck in limbo, time is critical. ERISA has short deadlines for appeals and lawsuits.
Here’s what you should do right now:
Save every letter and email from the insurance company and your employer.
Request the complete claim file in writing, including all medical reviews, internal notes, and communications used in the decision.
Do not ignore appeal deadlines. Missing the ERISA appeal deadline can destroy your case before it starts.
Call an ERISA life insurance attorney who handles these cases regularly and understands how to spot procedural violations.
Talk to a Life Insurance Lawyer About ERISA Procedural Violations
If you’re reading this after a denial, you probably feel:
Overwhelmed by the legal jargon in the denial letter
Unsure whether the insurer followed the rules
Worried you’re about to lose a benefit your family depended on
You don’t have to figure this out alone.
At Life-Insurance-Lawyer.com, we:
Focus on denied and delayed life insurance and AD&D claims, including those governed by ERISA
Carefully review the policy, claim file, and timeline to spot ERISA procedural violations
Build appeals and lawsuits that challenge both the substance of the denial and the insurer’s failure to provide a full and fair review
📞 If your employer-provided life insurance claim was denied or “under investigation,” call us at 1-888-510-2212 for a free consultation.
