Denied by your employer health plan? Your ERISA appeal rights

About 154 million Americans get health coverage through an employer. Most of those plans are governed by ERISA — the Employee Retirement Income Security Act — and its claims rules at 29 CFR 2560.503-1. If your insurance card came from a private-sector job (yours or a family member's), this guide is very likely for you.

Some employer coverage follows different rules:

• Government employer plans (state, city, county, public school) are outside ERISA, but most must still follow the federal ACA appeal and external review rules (45 CFR 147.136). If the plan is insured, external review usually runs through your state; if it is self-funded, it may use the federal HHS process instead. Your final denial notice must say how.
• Church plans are exempt from ERISA unless the plan chose to opt in. Ask the plan administrator which rules apply.
• Federal employee (FEHB) plans have their own separate appeal system run by the Office of Personnel Management (OPM), not ERISA.
• Marketplace, Medicare, and Medicaid plans are not ERISA plans either. For those, see our general guide, How to Appeal a Health Insurance Denial.

One more distinction matters a lot, and we cover it below: whether your employer plan is self-funded (the employer pays claims with its own money) or fully insured (the employer buys an insurance policy). Your internal appeal rights are the same either way — but the external review path is different.

Your deadline to appeal: at least 180 days. An ERISA group health plan must give you at least 180 days to file an internal appeal, counted from the day you receive the denial — not the date printed on the letter (29 CFR 2560.503-1(h)(3)(i)). That 180 days is a floor: a plan can give you more time, but never less. Check your denial letter for the exact date.

The plan's deadlines to decide your claim (29 CFR 2560.503-1(f)):

• Urgent care claims: as soon as possible, and no later than 72 hours. That 72 hours is a ceiling, not a target, and the plan gets no extension. If your treating physician says the claim is urgent, that determination controls.
• Pre-service claims (approval needed before care): 15 days, with one 15-day extension allowed only for reasons beyond the plan's control — and only if the plan tells you before the first 15 days run out.
• Post-service claims (care already received): 30 days, with one 15-day extension under the same conditions.
• The clock starts when you file — even if your claim is missing information (29 CFR 2560.503-1(f)(4)). The plan cannot restart the clock by calling your claim incomplete.

The plan's deadlines to decide your appeal (29 CFR 2560.503-1(i)) — and note there are no extensions at the appeal stage:

• Urgent appeals: 72 hours.
• Pre-service appeals: 30 days if the plan has one appeal level. If the plan uses two levels, it gets 15 days per level.
• Post-service appeals: 60 days for one level, or 30 days per level if there are two.
• A plan may require at most two internal appeals before you can move on (29 CFR 2560.503-1(c)(2)).

Before you write a single word of your appeal, use this: the plan must give you, free of charge and on request, copies of every document “relevant” to your claim (29 CFR 2560.503-1(h)(2)(iii)). This is the file the plan built when it denied you — and appealing without it means arguing blind.

“Relevant” is defined broadly (29 CFR 2560.503-1(m)(8)). It covers four categories:

Two related rights make the file even more useful:

• The internal rule behind the denial. If the plan relied on an internal rule, guideline, or protocol, the denial notice must say so and offer you a free copy (29 CFR 2560.503-1(g)(1)(v)(A)). For medical-necessity or experimental-treatment denials, the plan owes you the scientific or clinical explanation for how it applied the plan terms to your medical circumstances ((g)(1)(v)(B)).
• Who the plan's experts were. On appeal, you can get the identity of any medical or vocational experts whose advice the plan obtained — whether or not it relied on that advice (29 CFR 2560.503-1(h)(3)(iv)).

Send the claim-file request in writing, early, and keep a copy. Lysco generates this request letter for you free — it is the standard first step in our denial workflow for employer plans.

ERISA requires the plan to give your appeal a “full and fair review” (29 CFR 2560.503-1(h)). In practice that means:

• You can submit anything. Written comments, records, new test results, a letter from your doctor — the plan must accept and consider it all ((h)(2)(ii)).
• A genuinely fresh look. The appeal reviewer must consider everything you submit, must not defer to the original denial, and must be a different named fiduciary — not the person who denied you or that person's subordinate ((h)(2)(iv), (h)(3)(ii)).
• A qualified medical reviewer. If the denial rests on medical judgment, the plan must consult a health care professional with appropriate training and experience in the relevant field — and not one who was involved in the original denial ((h)(3)(iii), (v)).
• No surprise evidence (most plans). If your plan is not “grandfathered” (most are not — grandfathered means a plan that existed in March 2010 and has stayed essentially unchanged), the ACA adds this: any new evidence or new rationale the plan develops during your appeal must be given to you, free, sufficiently in advance of the decision so you can respond before it is final (29 CFR 2590.715-2719(b)(2)(ii)(C)).

Employer plans come in two types. In a fully insured plan, your employer buys an insurance policy and the insurance company pays claims. In a self-funded plan, your employer pays claims with its own money and usually hires an insurance company just to administer the paperwork. Your internal appeal rights are the same. But funding decides which external review process you use, and whether state insurance laws reach your plan.

How to find out — these are clues, not certainties, so confirm with your SPD or HR:

• Read your Summary Plan Description (SPD). Look for words like “self-funded,” “self-insured,” or “benefits are paid from the general assets of the employer.” A mention of “stop-loss insurance” suggests self-funded.
• Do not be fooled by the logo. “Administered by [big insurance carrier]” does not mean the plan is insured by that carrier. Many self-funded plans use a household-name insurer purely as administrator.
• Ask HR directly: “Is our health plan self-funded or fully insured?” They should know.
• Check the public record. Larger plans file a Form 5500 you can search free at efast.dol.gov (5500 search). The funding arrangement is listed on the form.

If you lose the final internal appeal, you can ask for an independent external review — a physician reviewer with no ties to your plan takes a fresh look, and the decision is binding on the plan. The federal process is free to you; a state process costs little or nothing. If the reviewer overturns the denial, the plan must provide coverage or payment without delay. A common myth says self-funded plans have no external review. That is false — but the path depends on your plan's funding:

• Deadline: request external review within 4 months of receiving the final internal denial.
• Timing: a standard decision within 45 days; expedited review within 72 hours when the normal timeline would seriously jeopardize your life, health, or ability to regain maximum function.
• Scope: external review covers denials involving medical judgment (as determined by the external reviewer), No Surprises Act compliance, and rescissions of coverage. It does not cover pure eligibility denials — for example, a dispute about whether you were enrolled in the plan at all.
• Grandfathered plans: exempt from most of these ACA add-ons, but since 2022 even grandfathered plans must offer external review for No Surprises Act items. The base ERISA rules in this guide apply to every ERISA plan, grandfathered or not.

Normally you must finish the internal appeals before going to external review or court. But if the plan fails to set up or follow the required claims procedures — for example, it blows its deadlines or will not give you your claim file — the law can treat your appeals as already finished (“deemed exhausted”), letting you skip ahead (29 CFR 2560.503-1(l)(1)).

Be careful here. Courts do not hand this out for trivial slip-ups. For non-grandfathered plans, the ACA version is stricter on plans, but it has a built-in exception: a violation does not count if it was (1) minor, (2) not prejudicial to you, (3) attributable to good cause or matters beyond the plan's control, (4) made in the context of an ongoing good-faith exchange of information, and (5) not part of a pattern of violations. All five must be true for the plan to keep you in the internal process. You can also demand a written explanation of any violation, and the plan must respond within 10 days (29 CFR 2590.715-2719(b)(2)(ii)(F)).

The practical takeaway: document every missed deadline and every ignored request. Even when a violation does not end the internal process, it strengthens your position at every later stage.

If appeals and external review fail, ERISA Section 502(a) lets you sue the plan in federal court to recover the denied benefit. An ERISA attorney is worth consulting for high-value denials, repeated procedural violations, or contested plan language. Go in with realistic expectations:

• Recovery is the benefit itself. A 502(a)(1)(B) suit recovers the denied benefit — not emotional-distress or punitive damages. That is why the cost-benefit math matters most for larger claims.
• Attorney fees are not automatic. Courts may award fees under 502(g)(1), at their discretion. Many ERISA attorneys offer free initial consultations — ask about fee structure up front.
• The deadline to sue is usually set by the plan. ERISA itself does not fix one, and plans commonly write their own limitation period into the plan documents — check your SPD, and do not assume you have years.
• Your appeal record is your court record. Courts usually decide ERISA cases on the record built during the internal appeals. Everything you submit — and every violation you document — during the appeal is what a judge will later see. That is another reason to take the internal appeal seriously even if you expect to lose it.