When a group life insurance claim is denied, the rules are very different from an individual policy denial. Most employer provided life insurance plans are governed by ERISA, a federal law that strictly controls how denials must be appealed and how lawsuits are handled. If you do not follow ERISA procedures precisely, you can permanently lose your right to recover benefits, even when the denial is wrong.
Under ERISA, you generally must file an administrative appeal with the insurance company before you are allowed to file a lawsuit. This appeal stage is not a formality. It is the most important part of the case and often determines whether the claim will ever be paid.
Understanding the ERISA Appeal Requirement
ERISA requires beneficiaries to exhaust administrative remedies before suing the insurer. This means you must submit a written appeal within the deadline stated in the denial letter, usually between 60 and 180 days. If the appeal is denied and you later file suit, the federal judge will only review the evidence that was submitted during this appeal process.
You do not get a second chance to add evidence later. There is no jury. There is no discovery. Everything rises or falls on what goes into the administrative record.
Step by Step Guide to Appealing a Denied ERISA Life Insurance Claim
Step 1: Read the Denial Letter Carefully
The denial letter is the roadmap for your appeal. ERISA requires insurers to explain the specific reasons for denial and cite the policy provisions they relied on. Common ERISA denial reasons include alleged failure to submit Evidence of Insurability, claims that coverage was not in effect, or assertions that the employee was not eligible under the plan.
The denial letter also states the appeal deadline. Missing that deadline can permanently bar your claim, regardless of merit.
Example
A surviving spouse received a denial stating her husband’s coverage ended before death. A careful reading revealed the insurer relied on missing payroll records rather than any policy exclusion. That distinction shaped the entire appeal strategy.
Step 2: Demand the Complete Claim File
Under ERISA, you have the right to request the insurer’s full claim file. This includes internal notes, communications with the employer, underwriting records, and any documents relied upon in the denial.
The claim file often reveals errors such as missing employer submissions, incorrect assumptions about enrollment, or reliance on documents that do not actually exist. Reviewing this file is critical before drafting the appeal.
Step 3: Gather and Submit All Supporting Evidence
The administrative appeal is your only opportunity to submit evidence. This includes:
Pay stubs showing premium deductions
Enrollment confirmations or benefit elections
Employer emails or HR records
Evidence of Insurability forms or proof they were never required
Medical records if insurability is disputed
Plan documents and summaries
You must assume that anything not submitted during the appeal will never be considered.
Example
In one case, a denial was reversed after email records showed the employee was auto enrolled during open enrollment and never informed that additional forms were required.
Step 4: File the Appeal Before the ERISA Deadline
ERISA deadlines are rigid. Appeals submitted even one day late can result in dismissal of a later lawsuit. Courts do not excuse late filings due to grief, confusion, or misinformation from the insurer.
Appeals should always be submitted in writing, by traceable delivery, with confirmation of receipt.
Step 5: Work With an ERISA Life Insurance Attorney
ERISA appeals are legal briefs, not simple letters. An experienced life insurance attorney can identify legal defects in the denial, draft a structured appeal, and ensure the record is complete.
Attorneys also know how to preserve arguments for federal court review, including challenges to the insurer’s decision making process and abuse of discretion.
Example
A family was denied benefits based on an alleged application error. Their attorney proved the employer completed the form incorrectly, leading to a full reversal at the appeal stage.
What Happens After the Appeal Is Filed
Administrative Review
Once the appeal is submitted, the insurer must conduct a full and fair review, usually within 60 days. The insurer may not ignore evidence or rely on new reasons that were not disclosed in the original denial.
Federal Lawsuit If the Appeal Is Denied
If the appeal is denied, you may file suit in federal court. The judge reviews the case based only on the administrative record. No new evidence can be added. There is no jury trial.
This is why the appeal stage is often more important than the lawsuit itself.
Common Reasons ERISA Life Insurance Appeals Fail
Many valid claims are lost due to technical mistakes, including:
Missing appeal deadlines
Incomplete documentation
Failure to address the exact policy language cited in the denial
Relying on phone calls instead of written submissions
Attempting to appeal without understanding ERISA procedures
Insurers know these rules well and often rely on beneficiaries making avoidable mistakes.
Take Action Before Your Rights Are Lost
If your group life insurance claim has been denied, do not assume you can fix it later. ERISA appeals are time sensitive and unforgiving. A properly prepared appeal can lead to payment without litigation, while a flawed appeal can permanently destroy an otherwise valid claim.