Frequently asked questions

Federal regulation requires your plan to give you at least 180 days following your receipt of the denial notice to file the internal appeal, not 180 days from the date printed on the letter. That is a floor, not the actual deadline: your specific plan document may allow more than 180 days, and the true deadline runs from when you received the notice, which can be later than its letter date. This is the deadline to file the internal appeal with your plan, not a deadline to file a lawsuit.

29 CFR 2560.503-1(h)(4), incorporating (h)(3)(i). Use the deadline calculator for an estimate based on your letter date.

Do not count on it. Many federal courts limit their review of a denied ERISA claim to the record that was in front of the plan when it decided the internal appeal, especially where the plan's decision gets deferential review. Whether a court will consider anything submitted later is genuinely disputed and cannot be relied on. Treat the internal appeal, not a future lawsuit, as your one chance to submit every piece of supporting evidence.

Discussed in the 2016 Department of Labor disability-claims rulemaking preamble, 81 Fed. Reg. 92316 (Dec. 19, 2016). See the administrative-record guide for the full explanation and its limits.

Only if your coverage is an employer- or union-sponsored group plan. ERISA generally does not apply to a policy you bought yourself outside of work, to government employer plans (federal, state, county, city, public school), or to church plans that have not elected ERISA coverage. If your plan is not ERISA-governed, the 180-day appeal deadline and the other federal rules described on this site generally do not apply to you, and a different process controls.

29 U.S.C. section 1003(a)-(b). Check your plan with the self-assessment.

Deemed exhaustion is a narrow rule: if your plan fails to follow the claims procedures the regulation requires, you may be treated as having already exhausted your internal appeal and allowed to sue right away. For disability claims the plan must strictly adhere to every requirement. A minor, good-faith procedural slip that does not harm you does not trigger this rule. It is not a general way to skip the appeal, and you should not rely on the plan making a procedural error.

29 CFR 2560.503-1(l)(1)-(2).

It depends on one sentence in your plan document. If the plan gives the administrator discretionary authority to decide eligibility or interpret plan terms, a court applies a deferential standard and asks only whether the decision was reasonable. If the plan document does not grant that discretion, a court reviews the denial de novo, deciding the claim fresh with no deference to the plan's decision. De novo is about deference, not about what a court may look at: many courts limit their review to the administrative record that was in front of the plan when it decided the appeal, and that limit is not lifted just because review is de novo, so do not count on putting new material in front of the court. You generally cannot tell which standard applies without finding and reading that specific plan-document language.

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989).

It is not legally required, but the internal appeal is generally the only chance to build the evidence record a later lawsuit will be limited to, and the rules governing what must go in the file are technical. On cost, this site does not state how ERISA LTD attorneys charge, because it has not sourced a figure for it. Ask any attorney you consult to set out in writing what the fee is and what you would owe in case costs if the claim does not succeed, before you engage them.

Read the full guide.

The regulation requires that whoever reviews your appeal on a medical-judgment denial, and any health care professional the plan consults about it, be a different person from whoever was involved in the original denial. That is a neutral-reviewer rule, not the same thing as an insurer-arranged independent medical examination: many LTD plans separately reserve a contractual right to send you to an IME with a doctor the insurer selects, and that right comes from your specific plan document, not from this federal regulation.

Source: 29 CFR 2560.503-1(h)(3)(ii)-(v).

Yes. You are entitled to request, free of charge, all documents, records and other information relevant to your claim, which includes material the plan looked at and did not rely on, not only what it cited in the denial letter. Request it in writing and keep a copy of your request.

29 CFR 2560.503-1(h)(2)(iii), (m)(8). Read the full guide.

For a disability claim, the plan generally must decide your appeal within 45 days of receiving it, with one possible extension of up to 45 more days for special circumstances, and with written notice to you before the initial period runs out. That is up to 90 days. The general ERISA rule for other benefit types is 60 days plus an extension of up to 60 more, so the disability rule is the shorter one at both ends. If your plan has two levels of internal appeal, each appeal gets its own 45 days: the 90 is a maximum per appeal, not a cap on the appeal stage as a whole, so do not treat the plan as out of time because 90 days have passed since your first appeal.

29 CFR 2560.503-1(i)(1)(i) and (i)(3)(i), with the group health contrast at (i)(2)(iii)(A).

There may be, and it is not the 180 days. A plan or policy can set its own cut-off for starting a lawsuit, called a contractual limitations period. You are not expected to work it out: for a disability claim, federal regulation requires the notice denying your appeal to describe any applicable contractual limitations period and to state the calendar date on which it expires for your claim. Find that date in your notice, and if it is not there, ask the plan administrator for it in writing. Missing it generally ends the case without a court reaching the merits, so do not assume that finishing the appeal leaves you with unlimited time.

29 CFR 2560.503-1(j)(4)(ii). Read the full guide.

You generally must complete the plan's internal appeal process before you can sue, and once you do, a lawsuit is usually limited to the record built during that appeal. At that point the practical options are typically a second internal appeal if your plan offers one, or filing a federal lawsuit under ERISA. Whether either makes sense depends on your plan's specific terms and the record you built, which is a decision to make with an attorney who handles ERISA LTD appeals. Before you weigh it, find the date your right to sue expires: the notice denying a disability appeal has to state the calendar date any contractual limitations period runs out.

Read the full guide.