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ERISA Benefit Claim Denial (Disability, Health and Pension Plans)

The federal rules for appealing, and then suing over, a denied claim under an employer-sponsored disability, health, life or retirement plan.

Informational only - this is not legal advice. These definitions explain general legal vocabulary in plain English. They are not advice about your situation, reading them creates no attorney-client relationship, and the law differs from state to state and changes over time. For advice you can rely on, speak to a lawyer licensed in your state.

Looking for a lawyer rather than a definition? Skip to the state-by-state list of law firms for this.

What it means

Most benefit plans that private employers provide, including long-term disability insurance, group health and life insurance, and pensions and 401(k) plans, are governed by the Employee Retirement Income Security Act. ERISA requires every such plan to have a claims procedure. A denial must be in writing and must give the specific reasons, refer to the plan terms it relies on, and describe what additional information would help. The claimant is entitled to a full and fair review of the denial on appeal, including access to the documents relevant to the claim. Plans run by government employers and most church plans are outside ERISA, and are governed by state law instead.

The internal appeal is the stage that usually decides the case. A claimant who later sues to recover benefits must ordinarily exhaust the plan's appeal first, and the court is then often limited to the record that was before the plan when it decided. Evidence that was not submitted in the appeal, such as a treating doctor's detailed opinion, functional testing or vocational evidence, may never be considered. The court reviews the denial anew unless the plan gives the decision-maker discretion. If it does, the court asks only whether the decision was an abuse of that discretion (Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989)), and a conflict of interest, as when the same insurer both decides and pays claims, is one factor in that review (Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105 (2008)).

ERISA largely displaces state law. State-law claims such as an insurer's bad faith in handling a plan claim are generally preempted (Pilot Life Insurance Co. v. Dedeaux, 481 U.S. 41 (1987)), so the remedy is usually the benefits due under the plan, with attorney's fees available at the court's discretion to a claimant who achieves some degree of success on the merits (Hardt v. Reliance Standard Life Insurance Co., 560 U.S. 242 (2010)).

Where this comes from

The Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001-1461. The claims-procedure requirement is 29 U.S.C. § 1133, with the Department of Labor's claims regulation at 29 C.F.R. § 2560.503-1; the suit to recover benefits is § 1132(a)(1)(B), attorney's fees § 1132(g)(1), preemption § 1144(a), and the exclusion of governmental and church plans § 1003(b). The standard of review is from Firestone, 489 U.S. 101, and Glenn, 554 U.S. 105.

When people hire a lawyer for this

Ask for a lawyer before you file the internal appeal, not after it is denied, because the appeal is usually the last chance to put evidence into the record a court will see. Request a complete copy of the claim file and the plan documents in writing, and read the denial letter for the appeal deadline, which the plan sets under the federal regulation. Many ERISA disability lawyers work on a contingency basis, because fees can be awarded against the plan.

Worried about the cost? A lawyer can be hired for one part of a case only (limited-scope representation), may be paid from what a claim recovers (contingency fee), or may be free through a pro bono program or legal aid; a court can also waive its own filing fees.

Find a lawyer for this in your state

Choose your state to see ERISA law firms in the city where we list the most; your city may be under “other cities”, A to Z.

Alabama (Birmingham)
+1 other city
- Montgomery
Alaska (Anchorage)
Arizona (Chandler)
+6 other cities
Arkansas (Little Rock)
California (Anaheim)
+21 other cities
- Bakersfield
- Chula Vista
- Fontana
- Fremont
- Irvine
- Long Beach
- Los Angeles
- Oxnard
- Riverside
- San Bernardino
- San Diego
- Santa Ana
- and 9 more with fewer listed firms
Colorado (Aurora)
+2 other cities
- Colorado Springs
- Denver
Connecticut (Bridgeport)
Florida (Hialeah)
+5 other cities
Georgia (Atlanta)
Illinois (Chicago)
Indiana (Fort Wayne)
+1 other city
- Indianapolis
Iowa (Des Moines)
Kansas (Wichita)
Kentucky (Lexington)
+1 other city
- Louisville
Louisiana (Baton Rouge)
+2 other cities
- New Orleans
- Shreveport
Maine (Portland)
Maryland (Baltimore)
Massachusetts (Boston)
Michigan (Detroit)
Minnesota (Minneapolis)
+1 other city
- Saint Paul
Mississippi (Jackson)
Missouri (Kansas City)
+1 other city
- St. Louis
Montana (Billings)
New Jersey (Jersey City)
+1 other city
- Newark
New York (Buffalo)
+3 other cities
North Carolina (Charlotte)
Ohio (Cincinnati)
+3 other cities
Oklahoma (Oklahoma City)
+1 other city
- Tulsa
Oregon (Portland)
Pennsylvania (Philadelphia)
+1 other city
- Pittsburgh
Rhode Island (Providence)
Tennessee (Memphis)
+1 other city
- Nashville
Texas (Arlington)
+12 other cities
Utah (Salt Lake City)
Virginia (Chesapeake)
+3 other cities
Washington (Seattle)
+1 other city
- Tacoma
West Virginia (Charleston)
Wisconsin (Madison)
+1 other city
- Milwaukee

Related terms

Other entries in the same area of law, each written from the same primary sources.

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Part of the LawyerLand plain-English legal glossary. Definitions are written from primary sources - statutes and court rules - and each entry states the authority it rests on, or says plainly when the doctrine is state law with no national rule.

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