What Is an ERISA Insurance Claim and How to File It?
Navigating the world of employer-provided benefits is challenging—especially after the loss of a loved one. Many families dealing with a denied life insurance claim quickly discover that the policy is governed by a federal law known as ERISA, the Employee Retirement Income Security Act of 1974.
ERISA claims are unlike standard insurance claims. The rules are stricter, the deadlines are tighter, and the appeal process is far more technical. A grieving beneficiary may not have the time, emotional capacity, or legal knowledge to prepare a comprehensive ERISA appeal—yet failing to submit the right documents could permanently damage their case.
This guide explains what an ERISA insurance claim is, how ERISA works, how to file an ERISA appeal, and what to do if your life insurance ERISA claim is denied.
What Is ERISA and How Does It Work?
ERISA is a federal law that regulates most employee benefit plans offered by private employers. These include:
Group life insurance
Group health insurance
Group disability insurance
Pension plans
Accidental death and dismemberment (AD&D) plans
If your life insurance benefits came from a policy connected to a private employer, union, or employee organization, your claim is almost certainly governed by ERISA.
Why ERISA Matters
ERISA requires that insurance plans:
Provide accurate plan information
Clearly explain coverage rules
Follow fiduciary responsibilities
Provide a fair claim and appeal process
Allow beneficiaries to sue for denied benefits
Unlike typical insurance lawsuits, ERISA lawsuits are filed in federal court, have no jury trial, and rarely allow new evidence. This is why filing a strong ERISA appeal is essential.
What Plans Are Covered by ERISA?
Your life insurance policy is likely governed by ERISA if:
Your employer pays all or part of the premiums
Your employer encourages employees to enroll
The employer keeps track of who participates in the plan
The employer answers questions about coverage
The employer distributes plan documents or benefit summaries
Plans Not Covered by ERISA
ERISA does not apply to:
Government employer plans
Public school employee plans
Workers’ compensation or unemployment benefit plans
Most church-sponsored benefit plans
If your plan falls under one of these categories, state law—not ERISA—controls your case.
Understanding ERISA Claim Procedures
ERISA claims are filed when someone seeks benefits from an ERISA-governed plan or challenges a denial. ERISA insurance claims differ from personal injury claims or employment law claims. They relate only to employee benefit plans.
Before filing a claim or appeal, it is essential to review:
Summary Plan Description (SPD)
Summary of Benefits and Coverage (SBC)
Eligibility definitions
For example, dependent life insurance policies may only cover children up to a certain age or may require that employees be “actively at work” to maintain coverage. Eligibility mistakes are a major cause of ERISA life insurance denials.
How to File an ERISA Claim
Your Summary Plan Description will specify:
Where to send completed claim forms
Required supporting documents
Claim administrator contact information
The ERISA claim process generally includes three steps:
1. Filing the Initial Claim
You start the ERISA claim process by submitting a written claim to the plan administrator. ERISA requires the administrator to respond—usually within 90 days—with either:
An approval, or
A denial containing detailed reasons
2. Filing an Internal ERISA Appeal
If the claim is denied, ERISA requires an internal appeal process.
You must submit:
A written appeal
All supporting documents
All legal arguments
Medical or financial evidence
Any additional proof you want considered
The plan administrator must reevaluate the claim and issue a decision.
3. External Remedies (ERISA Lawsuit)
If the internal appeal is denied, the beneficiary may file a federal ERISA lawsuit. Importantly:
You cannot file an ERISA lawsuit until you exhaust the internal appeal process.
Deadlines apply—so acting quickly is essential.
What If Your ERISA Claim Is Denied?
If a life insurance ERISA claim is denied, the insurer must provide a written denial letter that includes:
The reason(s) for denial
The plan provisions used to justify denial
Documents relied upon for the decision
What additional information is needed
How to submit an appeal
The deadline to appeal
Your right to file a lawsuit after appeal
You have the right to file an ERISA appeal, but the process is extremely strict.
Strict Deadlines for ERISA Appeals
The appeal deadline depends on the plan but is typically:
60 days, or
180 days from the denial letter
During this period, the beneficiary must:
Investigate the denial
Gather all relevant documents
Submit new evidence
Write a comprehensive legal appeal
Why the ERISA Appeal Is Critical
ERISA lawsuits generally prohibit new evidence.
This means:
If you fail to include important documents or arguments in your appeal, you may be barred from using them in court.
This is why working with an ERISA attorney early can dramatically increase your chances of winning.
What Happens if Your ERISA Appeal Is Denied?
If your appeal is denied, you have the right to file an ERISA lawsuit.
ERISA lawsuits differ from other cases in several ways:
Usually handled in federal court
No jury trial
Limited ability to introduce new evidence
The judge reviews only what’s in the administrative record
An experienced ERISA lawyer knows how to navigate these limitations, challenge the insurer’s decision, and argue for the benefits you deserve.
Why You Need an ERISA Life Insurance Lawyer
ERISA is one of the most complex areas of insurance law. A knowledgeable attorney can:
Request missing plan documents
Analyze eligibility rules
Identify fiduciary violations
Gather evidence insurers ignore
Draft a compelling appeal brief
Ensure compliance with deadlines
Build a strong administrative record
File a federal ERISA lawsuit if needed
Without legal help, many beneficiaries unintentionally weaken their own case.
Get Help With Your ERISA Life Insurance Claim
If your ERISA life insurance claim has been delayed, mishandled, or denied, you still have rights. Our ERISA attorneys can review your documents, explain your options, and help you recover the benefits owed under federal law.
📞 Call (888) 510-2212 for a free consultation.
We have the experience needed to win even the most complicated ERISA cases.
