Most employer provided life insurance policies are governed by ERISA. That includes group life insurance plans offered by private companies as part of a benefits package. When a claim under one of these plans is denied, the rules are very different from individual life insurance policies, and mistakes are harder to undo.
Before doing anything else, it is important to confirm whether ERISA applies. Once you are in the ERISA system, the appeal process becomes mandatory and highly procedural.
When ERISA Does and Does Not Apply
ERISA generally applies to life insurance offered through private employers. It usually does not apply to government employee plans or most church sponsored plans unless they opted into ERISA coverage.
If the insured worked for a private company, chances are high that ERISA controls the claim. You can often confirm this by looking at how the employer was involved.
Signs the policy is likely governed by ERISA include:
• the employer paid some or all of the premiums
• enrollment happened through HR or open enrollment
• the employer handled beneficiary forms or coverage questions
• plan documents like a Summary Plan Description were provided
If those factors are present, the appeal must follow ERISA rules whether you like them or not.
Why ERISA Life Insurance Claims Get Denied
ERISA denials often have less to do with the cause of death and more to do with administrative issues. Insurers and plan administrators rely heavily on technical compliance.
Common denial reasons include:
• alleged failure to enroll correctly
• missed or misapplied premium payments
• coverage ending when employment changed
• disputes over beneficiary paperwork
• strict interpretations of plan language
Even small administrative gaps can trigger a denial. Under ERISA, insurers are not required to give beneficiaries the benefit of the doubt.
Understanding the ERISA Appeal Requirement
If a claim is denied, ERISA requires the insurer or plan administrator to issue a written denial letter. That letter should explain why the claim was denied and outline how to appeal.
The appeal deadline is critical. Most plans allow either 60 or 180 days to file an appeal. If you miss that deadline, you usually lose the right to challenge the denial later.
Unlike non ERISA cases, you cannot skip the appeal and go straight to court. Completing the appeal is a legal requirement, not a suggestion.
Why the Appeal Stage Is So Important
ERISA cases are decided based on the administrative record. That means the judge will usually only consider documents that were submitted during the claim and appeal process.
If something is not raised during the appeal, it may never be considered at all. New evidence usually cannot be added later.
This is where many claims fail. Beneficiaries submit a short appeal letter, assume the insurer will reconsider, and do not realize they are building the only record the court will ever see.
What Should Be Included in an ERISA Appeal
A strong ERISA appeal does more than disagree with the denial. It addresses the insurer’s reasoning point by point and supports those arguments with evidence.
That may include:
• plan documents and policy language
• payroll or premium records
• enrollment confirmations
• beneficiary forms
• employment status records
• medical or factual clarifications
The appeal should also challenge improper interpretations of the plan and point out procedural errors when they exist.
Why Legal Help Often Changes the Outcome
ERISA appeals are not intuitive. They are deadline driven, document heavy, and unforgiving. Insurers know most beneficiaries do not understand the process and rely on that imbalance.
An attorney experienced with ERISA life insurance claims can:
• confirm ERISA applies
• identify weak points in the denial
• assemble a complete administrative record
• meet every procedural requirement
• preserve issues for court review
In many cases, the appeal itself resolves the claim. In others, it sets the foundation for a successful lawsuit.
When to Get Help With an ERISA Claim
The best time to speak with an ERISA attorney is as soon as a denial is issued. In some cases, it makes sense to involve counsel even earlier.
Situations that often lead to ERISA disputes include:
• the insured recently changed jobs
• employment ended due to illness or disability
• a conversion option was offered or missed
• coverage amounts changed close to death
• beneficiary designations were incomplete
These facts matter under ERISA and should be addressed early.