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/