Why You Shouldn’t Try to Navigate an ERISA Claim Alone

You’ve been disabled, denied health or pension benefits under your employer’s plan and are feeling frustrated—and maybe even helpless. You worked hard, paid into the plan and followed the rules. Now the benefits you need are being withheld.

It’s tempting to try to do it yourself, especially when the insurance company makes the process sound simple. But when it comes to ERISA claims, what looks simple on paper is often anything but. The Employee Retirement Income Security Act of 1974 (ERISA) governs these plans through a web of rules, deadlines and procedural traps that can make or break your case.

At Reynolds& ERISA Law Clinic, we’ve seen firsthand how complex and high stakes ERISA claims can be—and how much difference experienced legal help makes. Here’s why trying to navigate an ERISA claim alone can cost you your benefits and why having an attorney who knows the law can make all the difference.

1. ERISA’s Rules Are Complex and Inflexible

ERISA is a specialized area of law and even experienced general practitioners may struggle with its nuances. The statute and hundreds of related federal regulations and court decisions set out very specific procedures for filing claims and appeals.

For example:

• You may have only 60 days to 180 days to appeal after a denial.
• All evidence must be submitted before the appeal is decided, meaning new evidence can’t be added later in court.
• The plan administrator has strict obligations for notices, timelines and disclosures—but so do you.

Miss one deadline or omit one piece of evidence during the internal appeal and you may be forever barred from getting your benefits even if your claim was valid all along.

In short: ERISA cases are won or lost on the paperwork. Having an experienced attorney ensures every document, deadline and argument is done right from the start.

2. The “Administrative Record” Can Make or Break Your Case

One of the most misunderstood aspects of ERISA litigation is the administrative record—the file your plan administrator uses to decide your claim. If your appeal is denied and you go to federal court, the judge may only review this record, and you won’t be able to add new medical evidence, testimony or documentation later. So your internal appeal isn’t just a formality—it’s your one shot to build the case. Every medical record, expert opinion and factual statement must be included before the record closes.

An ERISA attorney knows how to build a comprehensive administrative record that preserves your rights and strengthens your position if litigation becomes necessary.

3. Insurance Companies and Plan Administrators Have Their Own Teams of Lawyers

Employer-sponsored health and welfare plans are often administered by large insurance companies with entire departments devoted to minimizing payouts. They know the legal system inside and out—and they count on the fact that most claimants don’t.

Without legal representation it’s easy to be outmatched by sophisticated plan administrators who know how to:

• Use vague “medical necessity” standards to deny claims
• Delay responses or misinterpret plan language
• Rely on in-house doctors who never personally examine you

Having an attorney levels the playing field. At Reynolds& ERISA Law Clinic, we hold plan administrators accountable to ERISA’s fiduciary standards and challenge unfair practices that violate the law.

4. Courts Give Deference to Plan Administrators Unless You Can Prove Otherwise

In many jurisdictions, a federal court will apply a legal standard known as the “arbitrary and capricious” standard of review. This means the judge won’t decide whether the decision was right or wrong; instead, she only determines whether the plan administrator’s decision was reasonable with the information it had at the time.

This standard favors the plan, but it’s not unbeatable. Skilled ERISA attorneys know how to present evidence in these cases, and find procedural errors, conflicts of interest, and evidence of bad faith that can convince courts to reverse a denial. Without an attorney most claimants never know how to raise these arguments or that they exist at all.

5. The Stakes Are Too High to Risk Mistakes

ERISA claims often involve benefits that are critical to your health and financial well-being:

• Long-term disability income
• Health insurance coverage for expensive medical treatment
• Pension or retirement benefits you’ve earned over decades

Losing these benefits can have long term consequences. An attorney who practices ERISA law knows not just the legal principles but also what’s at stake for you and your family.

At Reynolds& ERISA Law Clinic, we take a client-centered approach guiding you through the process, communicating clearly and ensuring your claim is presented with precision and care.

6. An Attorney Can Often Resolve Issues Before They Escalate

Not every ERISA dispute goes to federal court. Many times a well-prepared appeal with strong legal arguments can convince the plan administrator to reverse their decision internally.

An ERISA attorney can:

• Find legal errors in the denial letter
• Submit compelling medical and vocational evidence
• Communicate directly with the administrator or insurer to resolve the issue

In other words good legal work early on can prevent months or years of unnecessary litigation.

Why Having ERISA Counsel Matters

ERISA law is not just another area of employment or insurance law. It is its own system with its own rules, deadlines and remedies. Very rarely is the plaintiff entitled to discovery, a jury trial, or non-contractual damages. Your success depends on mastering the administrative process and federal procedural standards.

At Reynolds& ERISA Law Clinic, we extensively practice ERISA claims. Our attorneys know how to navigate the complex rules, hold fiduciaries accountable and protect your right to the benefits you’ve earned. Whether you’re facing a denied disability claim, a disputed pension or an unfair health benefit denial we bring the legal expertise and strategy these cases demand.

Your Future Starts with the Right Guidance

When you’re facing a denied ERISA claim the decisions you make in the first few weeks can determine the outcome for years to come. Missing a filing deadline, submitting incomplete records or relying on the insurer’s guidance can all cost you the benefits you deserve.

You don’t have to go it alone. Reynolds& ERISA Law Clinic is here to advocate for you—strategically, confidently and with deep experience in ERISA law.

Contact us today to discuss your case and get the legal support you need to protect your benefits and your future.

 

source https://www.reynoldsand.com/why-you-shouldnt-try-navigate-erisa-claim-alone/

ERISA and Mental Health Claims: What the Law Requires Insurers to Cover

For many employees and their families, access to mental health treatment is as important as coverage for physical conditions. Yet, countless individuals have claims for therapy, counseling or psychiatric care denied under their employer-sponsored health plans.

Luckily, federal law—specifically the Employee Retirement Income Security Act of 1974 (ERISA) and the Mental Health Parity and Addiction Equity Act (MHPAEA)—has got your back. These laws require insurance plans to treat mental health and substance use disorder benefits the same as medical and surgical care.

At Reynolds& ERISA Law Clinic, we represent individuals when insurers fail to follow these rules. This post explains how mental health coverage works under ERISA, what “mental health parity” really means and what to do if your mental health claim is denied.

What is Mental Health Parity

 

The Mental Health Parity and Addiction Equity Act (MHPAEA)—which runs alongside ERISA—prohibits group health plans from imposing more stringent limits on mental health or substance use disorder benefits than they do on medical or surgical benefits.

In other words, if your plan covers hospital stays, medications or outpatient visits for physical illnesses, it must cover the same for mental health conditions.

Parity applies to several areas, including:

• Financial requirements: Copays, deductibles and coinsurance for mental health care can’t be higher than for comparable medical care.
• Treatment limitations: The number of therapy visits or inpatient days can’t be capped more strictly than physical health services.
• Medical management: Plans can’t make it harder to get preauthorization for therapy or require extra proof of “medical necessity” for mental health care.

Example: If your plan allows 20 visits per year for physical therapy but only 10 visits for counseling, that’s likely a parity violation.

How ERISA Helps Employees and Plan Participants

ERISA covers most employer-sponsored health plans, including those that offer mental health coverage. It sets national standards for how claims are handled and gives participants the right to appeal denials and if necessary, sue in federal court.

Under ERISA, plan administrators must:

• Disclose mental health benefits and exclusions clearly.
• Explain denial decisions in writing, including the specific reason for the denial and the plan rules used to make that decision.
• Offer an internal appeal process within 180 days.
• Act in your best interest as fiduciaries, fairly and in compliance with federal law.

When plans don’t follow these rules—or apply mental health coverage more restrictively than physical health coverage—they may be violating both ERISA and the parity laws.

Why Mental Health Claims Get Denied

Despite federal protections, insurers deny mental health claims for reasons that don’t hold up under scrutiny. Here are common examples:

1. “Not medically necessary” – The insurer claims the treatment isn’t necessary, even when prescribed by a qualified provider.
2. “Experimental or unproven” – Certain therapies, like intensive outpatient programs, are wrongly categorized this way.
3. Coverage limits or visit caps – The plan limits therapy sessions or inpatient stays more strictly than physical health benefits.
4. Administrative technicalities – Missing forms, coding errors or late submissions can trigger denials, even when the care itself is covered.

Tip: Always request a copy of the plan’s medical necessity criteria and compare it to what’s required for similar medical conditions. Parity laws prohibit applying tougher standards to mental health care.

What to Do if Your Mental Health Claim Is Denied

 

1. Read the Denial Letter

ERISA requires that denial notices include:

• The reason for denial
• The specific plan provision involved
• What information is needed to perfect your claim
• How to file an appeal and by what deadline

Mark the 180-day appeal deadline immediately—missing it can forfeit your rights.

2. Get Key Documents

You’re entitled to copies of:

• The Summary Plan Description (SPD)
• Any internal guidelines used to make the decision
• The plan’s medical necessity criteria for mental health benefits

3. Gather Supporting Evidence

Include:

• Copies of medical records from all providers
• Detailed letters from your therapist, psychiatrist or physician
• Any other information showing medical necessity

4. File a Written Appeal

Submit a clear, organized appeal that addresses the reasons for denial. Point out any parity violations or inconsistencies in how the plan applies its rules.

             5.Get Legal Help

ERISA appeals are complicated and once your internal appeal is denied, courts may only review the “administrative record” of information already              submitted. Working with an attorney early ensures your appeal record is complete and strong enough for possible litigation.

            How Reynolds& ERISA Law Clinic Handles Mental Health Benefit Disputes

Mental health claims are denied not because care is unnecessary but because insurers misapply the law or use outdated medical necessity criteria.                Our attorneys at Reynolds& ERISA Law Clinic have years of experience finding these violations and holding insurers accountable.

We help clients by:

• Reviewing plan documents for parity and ERISA compliance
• Preparing and submitting detailed appeal packages
• Advocating for fair access to therapy, counseling and psychiatric care

Why Mental Health Parity Matters

Mental health conditions like depression, anxiety and trauma-related disorders are just as real and disabling as physical illnesses. Congress passed parity laws to ensure fair and equal access to treatment—and ERISA gives employees the right to enforce those protections.

When insurers deny legitimate mental health claims, they’re not just violating the law—they’re denying individuals the care they need to get better.

At Reynolds& ERISA Law Clinic, we believe no one should have to fight alone to get the mental health care their benefits promise.

If your mental health claim has been denied or restricted, schedule a consultation with Reynolds& ERISA Law Clinic today. Our attorneys can help you navigate the ERISA appeals process, assert your parity rights and get the coverage you deserve.

Equal Access to Mental Health Care

Knowing your ERISA and Mental Health Parity rights is the first step to protecting your access to care. If your employer-sponsored plan treats mental health differently than physical health, that’s not fair—it’s illegal.

With legal guidance, you can hold insurers accountable and make sure your mental health benefits are honored as the law requires.

Reynolds& ERISA Law Clinic can help you do just that.

 

source https://www.reynoldsand.com/erisa-and-mental-health-claims/

Short-Term vs Long-Term Disability Under ERISA

When you’re unable to work due to illness or injury, disability benefits can be a lifeline. But if your employer offers both short-term disability (STD) and long-term disability (LTD) benefits, it can be confusing to understand how they interact, what rules apply and what to do if your claim is denied.

The Employee Retirement Income Security Act of 1974 (ERISA) governs most employer-sponsored disability benefit plans. Knowing the difference between short-term and long-term disability and how ERISA impacts your rights can make all the difference in the claims process.

At Reynolds& ERISA Law Clinic, we focus exclusively on ERISA law, representing employees and plan participants in disputes over disability and health benefits. Below we’ll break down the key differences between short-term and long-term disability benefits, how they overlap and what you can do to protect your income.

What is Short-Term Disability (STD)?

Short-term disability benefits are designed to replace part of your income for a limited time when you can’t work due to illness, injury or recovery from surgery.

Key features:

• Coverage lasts for a limited amount of time, depending on the plan.
• Some STD plans provide salary continuation through payroll, while others pay a percentage of your salary through an insurance policy.
• Some plans require you to use sick leave or vacation time before STD kicks in.
• STD claims are usually processed faster than LTD claims.

Example: If you need three months off work to recover from back surgery, STD benefits may provide income replacement during your recovery period.

What is Long-Term Disability (LTD)?

Long-term disability benefits provide income replacement if your condition prevents you from working for an extended period of time.

Key features:

• Payments typically begin after STD benefits run out, after a non-paying “elimination period” of 90–180 days.
• Benefits can last for years—or in some cases until retirement age.
• LTD typically pays a percentage of your salary, often 50–60%, but the exact amount depends on your plan.
• Plans may define “disability” more strictly after two years, requiring proof you can’t work any occupation, not just your own.
• Many LTD plans also limit the duration of payments for certain types of disabilities (for example, for mental health disabilities)

Example: If a chronic illness prevents you from returning to work after six months, LTD benefits may provide ongoing income support.

How STD and LTD Work Together

Most employees transition directly from STD to LTD if their disability continues. Think of STD as the bridge that provides income until LTD coverage begins.

Important considerations:

• Elimination period: LTD benefits don’t start immediately. You’ll often need STD benefits (or another income source) to cover this gap.
• Medical documentation: The evidence you submit for your STD claim often forms the basis of your LTD claim. Consistency in medical records is key.
• Overlapping coverage: Some employers offer only one type of plan, others offer both. Knowing what your employer offers is crucial.

ERISA Rules

ERISA governs some employer-sponsored STD and nearly all LTD plans. This includes:

• Your right to receive plan documents, including the Summary Plan Description (SPD).
• Requirements for clear explanations of claim denials.
• Right to file an appeal within 180 days of a denial.
• Fiduciary duties for plan administrators to act in your best interest.

Note: Short-term disability plans may be exempt from ERISA if benefits are paid directly by the employer through payroll. If payments are made by an insurance company, the plan most likely falls under ERISA’s protections.

Common Employee Challenges

1. Denials for lack of medical evidence
   Administrators may argue your medical records don’t support disability.
2. Inconsistent definitions of disability
   STD and LTD plans sometimes use different definitions which can cause confusion when transitioning from one to the other.
3. Failure to meet deadlines
   Missing the 180-day appeal deadline under ERISA can bar your claim forever.
4. “Any occupation” standard in LTD
   Many LTD plans shift definitions after two years requiring proof you can’t work any occupation, not just your prior role.

What to Do

1. Get your plan documents early. Know the elimination periods, benefit levels and definitions of disability in both STD and LTD plans.
2. Keep thorough medical records. Ensure your doctors provide detailed specific notes about your condition and limitations.
3. Be consistent. Discrepancies between STD and LTD applications can lead to denials.
4. Meet every deadline. ERISA timelines are strict and missing them can end your claim.
5. Get legal guidance early. An ERISA attorney can help you strengthen your claim record in case litigation becomes necessary.

 Why STD vs. LTD Matters

For employees, it’s not just about the words – it’s about survival during a medical crisis. STD is a bridge, LTD is a lifeline. Both have complex rules and ERISA requirements.

At Reynolds& ERISA Law Clinic, we help employees and plan participants sort through the confusion, navigate overlapping benefits and fight denials.

If you’re having disability issues, don’t wait until deadlines pass. **Schedule a consultation with Reynolds& ERISA Law Clinic today to protect your income and your future.

Income Protection Through Every Stage of Disability

Illness or injury can turn your world upside down, but disability benefits are meant to be a safety net. By understanding the difference between short-term and long-term disability, how they overlap and how ERISA applies to your rights, you can better protect your income and focus on recovery. With the right help, you can get the benefits you’re entitled to.

 

source https://www.reynoldsand.com/short-term-vs-long-term-disability-under-erisa/

Former NFL Linebacker Ka’lial Glaud Sues NFL Player Disability & Survivor Benefit Plan, Alleges Biased Process by Plan Doctors

Former NFL linebacker Ka’lial Glaud, who played for the Tampa Bay Buccaneers and Dallas Cowboys after a standout career at Rutgers University, has filed an ERISA lawsuit against The NFL Player Disability and Survivor Benefit Plan and two of its Medical Advisory Physicians (MAPs): William Simon Garmoe, MA, Ph.D., and Silvana Riggio, M.D.

Filed in the U.S. District Court for the District of New Jersey on September 9, 2025 (Glaud v. NFL Disability and Survivor Plan, et al., No. 1:25-cv-15373), the complaint seeks (1) disability benefits the Plan allegedly owes and (2) the removal of the two MAP physicians for alleged breaches of fiduciary duty under the Employee Retirement Income Security Act of 1974 (ERISA).

“This lawsuit builds upon several other cases filed against the NFL Disability and Survivor Plan in the past several years, all of which have shown that the Plan continues to act in a self-serving manner,” said William Reynolds, one of Glaud’s attorneys. “In addition to seeking what is owed to Ka’lial, we are seeking the novel remedy of removal of two of the MAP physicians that have crafted the administrative procedures that allow the systematic denial of benefits to all participants.”

Glaud is represented by William Reynolds, clinical professor at Chicago-Kent College of Law, and Richard Frankel of Bross & Frankel, P.A. (Cherry Hill, NJ).

What the lawsuit alleges

According to the complaint:

• Glaud suffered multiple concussions during his playing career and has ongoing neurocognitive impairments.

• He has not returned to full-time employment since September 2015.

• He applied for Neurocognitive Disability benefits and underwent at least seven independent examinations over several years.

• Although physicians allegedly found consistent and reliable evidence supporting disability, the Plan denied benefits.

• The denial, the suit claims, flowed from a biased process designed and enforced by the Plan’s MAP physicians, who are highly paid and have authority to overrule treating doctors and even the Plan’s own examining physicians.

• Beyond benefits for Glaud, the suit seeks to remove Dr. Garmoe and Dr. Riggio as Plan fiduciaries, alleging they failed to act in participants’ best interests, causing economic harm to Glaud and other Plan participants.

Why this case matters for ERISA claimants

For former professional athletes and employees alike, ERISA is meant to protect participants in employer-sponsored benefit plans—including long-term disability, health benefits, and pension and retirement plans. Cases like Glaud’s highlight recurring issues we see across many ERISA plans:

1. Structural conflicts of interest
   When plan-appointed medical reviewers can override treating specialists, questions arise about impartiality and fiduciary duty.

2. Administrative gatekeeping
   Complex internal procedures can delay or deny legitimate claims, especially in neurocognitive disability matters where evidence may require longitudinal testing and specialist interpretation.

3. Remedies beyond back benefits
   ERISA allows courts to address fiduciary breaches, which can include restructuring decision processes or, as sought here, removal of fiduciaries whose actions allegedly harm participants.

Quick explainer: ERISA disability & “MAP” physicians

• What is ERISA?
  The Employee Retirement Income Security Act sets federal standards for employer-sponsored benefit plans, including claim procedures and fiduciary obligations.

• What are MAP physicians?
  In some plans (including the NFL plan), Medical Advisory Physicians advise or influence benefit decisions. The lawsuit alleges these MAPs designed and enforced procedures that produce systematic denials—an alleged breach of fiduciary duty if proven.

• What evidence matters in neurocognitive claims?
  Records often include neuropsychological testing, imaging when appropriate, treating provider opinions, and functional capacity evidence showing how symptoms affect work on a reliable, sustained basis.

If your disability or pension claim was denied, here’s what to do next

Whether you’re a former professional athlete, union member, or employee covered by a private employer plan in Chicago, a denial is not the end:

1. Get the administrative record.
   Under ERISA, your appeal is usually limited to the evidence in the claim file. Request it promptly.

2. Mind the deadlines.
   ERISA appeals have strict timelines—often 180 days from denial. Missing them can foreclose relief.

3. Strengthen the medical evidence.
   Targeted neuropsychological or specialty evaluations, longitudinal records, and work-impact documentation can be decisive.

4. Spot procedural errors.
   Biased reviewer selection, selective evidence weighting, or failure to engage with treating opinions can support an appeal or litigation.

5. Consult an ERISA attorney early.
   Building a comprehensive administrative record is critical before filing suit.

About Reynolds& — ERISA Lawyers in Chicago

Reynolds& — ERISA Law Clinic focuses exclusively on ERISA law. We represent employees, plan participants, and beneficiaries in disability insurance, health benefits, pension and retirement plan disputes, and fiduciary duty claims.

• Address: 565 W Adams St, Suite 627, Chicago, IL 60661

• Phone: (312) 906-5038

• Hours: Mon–Fri, 9:00 a.m.–5:00 p.m.

• Practice Focus: ERISA litigation, long-term disability claims, short-term disability appeals, pension benefit disputes, fiduciary breaches.

Facing a denied disability claim or pension dispute?
Call (312) 906-5038 or request a consultation today. Our Chicago ERISA attorneys help plan participants pursue the benefits they’ve earned.

Disclaimer

This post summarizes allegations in a complaint filed on September 9, 2025 in the U.S. District Court for the District of New Jersey. Allegations are claims, not findings. Outcomes depend on the facts and the law. This post is informational and not legal advice; reading it does not create an attorney-client relationship.

source https://www.reynoldsand.com/kalial-glaud-nfl-disability-erisa-lawsuit/

Your ERISA Rights: A Guide for Plan Participants

Dealing with employee benefit plans can be complicated, especially when problems arise. Fortunately, the Employee Retirement Income Security Act of 1974 (ERISA) provides a legal framework to protect employees who participate in employer-sponsored benefit plans. Whether you’re in a retirement plan, health insurance or disability plan through your employer, ERISA gives you specific rights and protections.

At Reynolds& – ERISA Law Clinic, we focus exclusively on ERISA and know what employees face when trying to get the benefits they’ve earned. In this post, we’ll break down your ERISA rights and how they can help you secure your future.

What is ERISA?

ERISA is a federal law that covers most private-sector employee benefit plans, including health insurance, retirement plans (like 401(k)s and pensions) and disability insurance. It sets standards for plan management, fiduciary responsibilities, reporting and disclosure requirements and procedures for appealing denied claims.

Originally enacted to ensure employees get the benefits promised by their employers, ERISA has evolved over the years through amendments and case law to become a safety net for millions of American workers.

ERISA Protections for Employees

 

1. Right to Know

 

ERISA requires plan administrators to give participants important information about their plans. This includes a Summary Plan Description (SPD) which explains how the plan works, what benefits are available and how to file a claim. Participants can also request other plan documents, including annual reports and funding information. These documents are key to understanding your benefits and holding plan administrators accountable.

2.Fiduciary Duties

Those who manage and control plan assets are considered fiduciaries and must act in the best interests of plan participants. They must act prudently, diversify investments and avoid conflicts of interest. Fiduciaries must also follow the plan’s terms unless those terms conflict with ERISA. If a fiduciary fails in these duties, participants may have legal recourse.

3.Claims and Appeals Process

ERISA requires a fair and timely process for reviewing and appealing denied claims. If your claim for benefits is denied, the plan must give you a written explanation including the reasons for the denial and the specific plan provisions on which it is based. You must also be given an opportunity to appeal the decision within a certain time frame, usually 180 days. This internal appeals process is the first step before you can pursue legal remedies in court.

4.Right to Sue

If your benefits are wrongfully denied or if fiduciaries mismanage plan assets, ERISA gives you the right to file a lawsuit in federal court. This includes claims for unpaid benefits, breaches of fiduciary duty and failure to provide required information. Courts can order payment of benefits, enforce plan provisions and in some cases award attorney’s fees.

5.Protections Against Retaliation

ERISA prohibits employers from retaliating against employees who assert their rights under the law. This includes protection for those who file claims, request information or report plan mismanagement. If your employer demotes, fires or discriminates against you because of your ERISA-protected actions, you may have a claim for retaliation.

ERISA Issues Employees Face

• Denied disability or health benefits without explanation
• Mismanagement of retirement plan investments resulting in financial loss
• Failure to provide required plan documents or annual disclosures
• Employer retaliation after benefit claims or internal complaints

Employees may not always know when ERISA rights are being violated. For example, a vague or delayed explanation for a denied claim may seem like red tape but it could actually be noncompliance with ERISA’s procedural requirements. Confusion about benefit eligibility might be due to unclear or incomplete plan documentation.

Reynolds& – ERISA Law Clinic Can Help

At Reynolds& – ERISA Law Clinic, we specialize in representing employees, plan participants and beneficiaries in ERISA matters. We make sure your rights are protected and you get the benefits you’re entitled to. Whether you’re dealing with a denied claim, a complex pension issue or a fiduciary violation, our legal team provides strategic, client-centered support.

We help clients understand their plans, navigate complex appeals and take legal action when necessary. Our ERISA litigation experience allows us to advocate effectively in administrative processes and federal court.

Your ERISA Rights Are Your Financial Safety Net

ERISA is your safety net. Know your rights and take action to get the benefits you’re owed and hold plan administrators responsible. If you think your ERISA rights have been violated, contact us.

Having an ERISA attorney on your side can mean the difference between a denied claim and a successful appeal. Contact us today to get started.

 

source https://www.reynoldsand.com/your-erisa-rights-a-guide-for-participants/

What to Do When Your Disability Claim Is Denied Under ERISA: A Step-by-Step Guide

Getting denied disability benefits under your employer’s plan can be really tough, especially when you’re already dealing with a serious health issue. If your claim is ERISA-governed, you need to know your rights—and what to do next. Here’s a clear, actionable guide to help you go from denial to potential recovery of benefits.

Step 1: Don’t Freak Out—But Don’t Delay

 

First, take a deep breath. A denial isn’t the end. Under ERISA, you have the right to appeal the denial through your plan’s internal claims process. But the clock is ticking: ERISA has strict deadlines— 180 days from the date of denial—to file an appeal. Missing this deadline can forfeit your right to further challenge the decision, including through litigation.

 

Step 2: Read the Denial Letter Carefully

Your first move should be to read the denial letter thoroughly. ERISA requires denial notices to clearly state:

• The specific reasons for the denial
• References to the plan provisions on which the decision was based
• A description of any additional information needed to perfect the claim
• Information about your appeal rights and deadlines

See if the denial was due to lack of medical evidence, a dispute over your job duties, or a finding that you don’t meet the plan’s definition of “disability.” This will help guide your appeal.

Step 3: Get the Claim File and Plan Documents

You have the right to get your entire claim file and plan documents, including the Summary Plan Description (SPD), which outlines the plan terms, definitions and appeal procedures. These documents are key to:

• Understanding how “disability” is defined
• Identifying any discretionary authority given to the insurer
• Confirming the insurer followed procedure

The claim file will have all medical reviews, vocational assessments and internal notes used in the decision.

 

Step 4: Build an Administrative Record

The administrative appeal is your one and only chance to submit evidence in support of your claim. If your appeal is denied and the case goes to federal court, the judge will only review what’s in the administrative record—you won’t get a do-over.

Your goal is to create a complete and compelling case that includes:

• Updated medical records
• Physician letters detailing your diagnosis, symptoms and functional limitations
• Personal statements and witness affidavits
• Functional capacity evaluations or independent medical exams (IME), if available

You should directly rebut any medical reviews conducted by the insurer’s in-house consultants or hired physicians. If they misinterpreted your condition or ignored your treating doctor’s opinions, say so—backed by clear documentation.

Step 5: Write a Winning Appeal Letter

Your appeal letter should be factual, concise and assertive. Address the reasons for denial point by point. For example:

• If the insurer claims there’s “no objective evidence” of impairment, cite diagnostic tests or functional assessments.
• If they argue your condition doesn’t prevent you from working, explain—using job descriptions and medical input—why that’s not true.

A well-crafted appeal letter serves not just to reverse the denial but also to set up the strongest possible record for any future litigation.

Step 6: Consider Getting Legal Help

Although you can file an appeal on your own, the ERISA claims process is legalistic and insurer-friendly. A skilled ERISA attorney can:

• Identify procedural violations that can strengthen your case
• Coordinate with your doctors to provide targeted medical support
• Draft a compelling legal and medical argument
• Preserve all appellate rights if the matter goes to court

At Reynolds& – ERISA Law Clinic, we’ve helped many people get benefits after a denial. We know how insurers think—and how to challenge them effectively.

 

Step 7: File Your Appeal on Time

Once your appeal is complete, file it within the 180-day deadline. Keep records of everything you send, including certified mail receipts or digital confirmations.

Under ERISA, the plan administrator must issue a decision on your appeal—usually within 45 days, with a possible 45-day extension. If they uphold the denial, you’ll then have the right to file a lawsuit in federal court.

From Denial to Win: Why the Right Strategy Matters.

A denial of your disability claim under ERISA isn’t the end—it’s a hurdle you can overcome with the right information, documentation and legal guidance. Every step you take after a denial is critical and building a strong administrative record can make all the difference in getting your benefits back.

Don’t go it alone. At Reynolds& – ERISA Law Clinic, we help plan participants like you through the appeals process and take legal action when needed. We know ERISA inside and out and how to take on the insurers.

Call us today for a free consultation and let us turn your claim around. Your benefits and your future deserve strong advocacy.

 

source https://www.reynoldsand.com/what-to-do-when-your-disability-claim-is-denied-under-erisa/