Denied Disability Benefits? How ERISA Appeals Work
Insurers often deny disability claims due to missing paperwork, conflicting medical reports, administrative mistakes, or because they decide you don’t meet their policy’s definition of disability. Denials frequently happen when insurers overlook important medical evidence or misrepresent the physical and mental requirements of your job, or even the medical evidence itself.
Vague language in your policy or mishandling of supporting documents can also result in a denied claim. If you receive a denial, an experienced disability lawyer can pinpoint where your application fell short and guide you through the next steps.
Your Rights Under ERISA
If your long-term or short-term disability benefits are provided through a group plan at work, they are almost always subject to ERISA. ERISA sets strict deadlines and procedures for appealing a denial. After your claim is denied, you typically have just 90 or 180 days to file a detailed, written appeal with your insurer.
This appeal is your only opportunity to submit new evidence—such as medical records, statements from your doctors, witness statements, or vocational expert reports. Missing this window or submitting an incomplete appeal could make it almost impossible to win in court later.
How the ERISA Appeals Process Works
The ERISA disability appeal process is somewhat technical, time-sensitive, and governed by strict federal rules. Here’s a step-by-step guide to what happens next:
- Request the Full Administrative Record
After a denial, your first step should be to request your entire claim file in writing, and any materials the insurer relied upon in making their decision. Under federal regulations, the insurer must provide these documents for free, including internal notes, medical reviews, third-party opinions, surveillance reports, and all correspondence.
- Prepare and Submit Your Appeal—With All Supporting Evidence
Your written appeal should directly address every reason given for the denial, which may not all be contained in the denial letter, with detailed medical, vocational, and factual support. You must submit all evidence you want the insurer and (if needed) ultimately the federal court to consider. This is your only opportunity to provide new medical evaluations, supporting letters from your treating physicians, job descriptions, personal statements, or witness affidavits.
In some states, some disability policies may try to use “discretionary clauses” to make appeals harder. However, many state laws restrict their use—an ERISA lawyer can ensure your rights are protected under ERISA insurance regulations.
- Insurer’s Review Timeline and Decision
The insurer must review your appeal within 45 days, with a one 45-day extension available to them (you must be notified in writing if more time is needed). They must provide a clear, written final decision, explaining the reasons and referencing specific policy provisions. If your appeal is denied, you have the right to file a lawsuit in federal court.
- Filing a Federal Lawsuit (If Needed)
If the appeal is unsuccessful, you can bring a lawsuit against the insurer—but the federal judge will usually only review the “administrative record,” i.e., the evidence you already submitted. That’s why building a complete record during the appeal is critical; new information and arguments are rarely allowed later.
- Get Professional Support From the Start
Because ERISA appeals are technical, high-stakes, and often adversarial, most claimants benefit from the support of a seasoned ERISA attorney. Insurance companies have their own legal and medical teams—don’t go up against them alone.
Start Your ERISA Appeal with Todd Krauss, APC
The ERISA appeals process is your one true chance to reverse a disability benefit denial. Don’t leave your financial future to chance or the insurance company’s interpretation. Todd Krauss, APC has the experience and commitment needed to handle even the most challenging disability denials—offering strategic support from the first appeal through possible litigation. If your disability claim has been denied anywhere in California, contact us today for a confidential case evaluation and take the first step toward recovering the benefits you deserve.
