If an employer-sponsored health plan denies a claim, the written notice should explain the reason and how to appeal. Many private employer plans governed by ERISA must provide a full and fair review, relevant claim documents without charge, and at least 180 days to file an initial appeal. The precise rules depend on the plan.
Identify the plan before choosing a legal route
ERISA governs many private-sector employer benefit plans, including many self-funded and fully insured employer health plans. It does not automatically govern individual Marketplace policies, government employee plans, or church plans. Medicare, Medicaid, TRICARE, and VA programs have different review systems and deadlines.
Ask the employer or plan administrator for the Summary Plan Description and governing plan documents. The name printed on an insurance card may identify only the claims administrator, not the entity funding benefits. That distinction can affect regulation, appeals, and which party ultimately bears the cost.
What a denial notice must explain
The U.S. Department of Labor explains that a covered ERISA health claim denial generally must identify specific reasons, the plan provisions relied on, information needed to perfect the claim when relevant, and the appeal process. Medical-necessity denials must also address the applicable clinical judgment or criteria under governing rules.
If a letter merely says ‘not medically necessary,’ request the actual plan language, clinical guideline, and patient-specific facts supporting the decision. An internal code without a comprehensible explanation is not a satisfactory substitute for a reasoned determination.
What records may a claimant request?
Under the Department of Labor’s claims-procedure framework, relevant documents, records, and other information used in a benefit determination generally must be made available without charge on request. Ask for the claim file, relevant internal guidelines, reviewer information where applicable, and records considered in reaching the decision.
Make the request in writing and preserve proof of delivery. Suggested language: ‘Please provide without charge all documents, records, clinical guidelines, and other information relevant to the adverse benefit determination for claim [identifier], including the specific plan terms and criteria relied upon.’ Use a secure submission channel for medical information.
How long is the initial appeal period?
The Department of Labor states that a claimant under the applicable ERISA claims-procedure rules generally has at least 180 days after receiving an adverse benefit determination to request an initial internal appeal. Some plans allow longer. Other insurance systems have different time limits, and urgent situations may follow special rules.
Record the date the notice arrived, the deadline stated, and the permitted submission methods. Send through an approved channel and keep a receipt. When different documents suggest different deadlines, request written clarification while protecting the earliest plausible deadline.
What does full and fair review mean?
The appeal generally must receive a fresh review, not merely a rubber stamp from the original decision-maker. When medical judgment is involved, appropriately qualified medical professionals may need to be consulted. Under the Department of Labor framework, the reviewer cannot be the original decision-maker or that person’s subordinate.
Address the stated denial reason. If the insurer says a required treatment trial is missing, submit records showing the trial or a clinician’s explanation of contraindication. If the plan excludes a benefit, a medical-necessity letter alone may not resolve the contractual exclusion; review the precise plan terms.
What follows a final denial?
The final decision should explain its reasons and applicable further procedures. Depending on the plan and claim, independent external review or litigation may be available. ERISA litigation is specialized, and internal exhaustion rules and the administrative record can be important.
The Department of Labor’s Employee Benefits Security Administration can help people understand an ERISA plan’s claims procedures. Consider qualified legal help when a deadline is near or substantial treatment is at stake. For organizing evidence, see our denial-appeal guide.
Frequently asked questions
Does every insurer provide 180 days? No; that figure applies to initial appeals under the relevant ERISA claims-procedure framework, not every coverage program. Can a claimant request the rule used in a denial? Many covered ERISA claimants can obtain relevant clinical guidelines and records.
Can someone sue immediately? Not necessarily. Internal review and procedural requirements often matter; seek case-specific legal advice before assuming a court route.
Sources and further reading
U.S. Department of Labor: Filing a Claim for Your Health Benefits
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