How to Appeal a Denied Benefit Claim From an Employer Retirement Plan

What should you do after your retirement benefit claim is denied?

Start with the plan's denial notice. An ERISA-covered retirement plan must maintain a reasonable written procedure for benefit claims and appeals, and the Summary Plan Description should explain the claims procedure.

A denial is not the end of the internal process. Federal rules require an opportunity for a full and fair review of an adverse benefit determination. For an ordinary retirement benefit claim, you generally must be given at least 60 days after receiving the denial to request that review.

This process is for employer retirement benefits, not Social Security retirement benefits. If you are preparing for Social Security retirement instead, the separate Helpydo guide explains how to apply for Social Security retirement benefits.

What should the denial notice tell you?

The plan's adverse benefit determination must provide information that allows you to understand the decision and use the review procedure. Under the ERISA claims regulation, the notice generally must include the specific reason or reasons for the denial and reference the specific plan provisions on which the decision is based.

If additional material or information is necessary to perfect the claim, the notice must describe what is needed and explain why it is necessary. It also must describe the plan's review procedures and applicable time limits and include a statement concerning the claimant's right to bring a civil action under ERISA section 502(a) after an adverse benefit determination on review.

Use these explanations as the structure for your appeal. Address the plan's stated reasons instead of submitting only a general statement that you disagree.

How long do you have to appeal?

For an ordinary retirement benefit claim, Department of Labor guidance states that you have 60 days to request a full and fair review of the denied claim. The claims regulation requires a reasonable period of not less than 60 days after receipt of the adverse benefit determination for appeals of claims other than group health and disability claims.

Your plan may provide a longer period, so check the denial notice and Summary Plan Description. Do not assume that a longer deadline used for another type of employee benefit applies to a retirement claim.

Keep evidence showing when you received the denial and when the appeal was submitted. The plan's procedure should identify where and how the appeal must be filed.

What should you include with the appeal?

Explain specifically why you believe the plan's decision is incorrect. Depending on the dispute, useful evidence can include employment and service records, benefit statements, contribution records, beneficiary records, plan communications or calculations relevant to the benefit being claimed.

Under the federal claims procedure rules, the appeal process must allow you to submit written comments, documents, records and other information relating to the claim. The review must take into account all information you submit relating to the claim, whether or not that information was submitted or considered in the initial benefit determination.

You also must be given, upon request and free of charge, reasonable access to and copies of documents, records and other information relevant to the benefit claim. Requesting the relevant claim file can help you understand how the plan reached its decision.

How long does the plan have to decide your appeal?

For a retirement benefit claim subject to the general ERISA review timetable, the plan administrator must notify you of the determination on review within a reasonable period, generally no later than 60 days after receiving your request for review.

If special circumstances require more time, the plan can extend the review period by up to another 60 days. It must provide written notice of the extension before the initial period ends, identify the special circumstances requiring the extension and state when it expects to make the decision.

There is an important procedural exception. When a plan uses a committee or board of trustees as the appropriate fiduciary and that body holds regularly scheduled meetings at least quarterly, the federal regulation permits a meeting-based decision timetable. Your Summary Plan Description should explain the review procedure that applies to your plan.

What happens after the plan reviews the appeal?

The plan must provide notice of its decision. If the appeal remains denied, the notice must explain the specific reasons for the adverse decision and refer to the plan provisions on which the decision is based.

The notice also must explain your right to receive relevant documents free of charge and include a statement describing your right to bring an action under ERISA section 502(a). Department of Labor guidance also states that the notice should describe any additional or voluntary appeal levels offered by the plan.

A voluntary additional appeal is different from the appeal required under the federal claims rules. If your plan offers another voluntary review level, read its terms carefully before deciding whether to use it.

When should you contact EBSA?

The U.S. Department of Labor's Employee Benefits Security Administration assists participants and beneficiaries with retirement plan rights under ERISA. Contact EBSA if you do not receive a written decision on your claim or appeal, cannot get a response from a plan official, believe the plan failed to follow ERISA's claims requirements, or need help understanding your retirement plan rights.

You can request assistance electronically through Ask EBSA or call 1-866-444-3272. EBSA states that Benefits Advisors handle complaints involving alleged violations of Title I of ERISA and can seek informal resolution when appropriate.

When asking EBSA for assistance, it is useful to have your name and contact information, a brief explanation of the problem, evidence that you filed a benefit claim, and the employer or plan official's contact information. EBSA also advises participants to continue following their plan's filing and appeal procedures on time while seeking assistance.

Does ERISA cover every employer retirement plan?

No. ERISA sets federal standards for many private-sector employer retirement plans, but its Title I protections do not apply to every retirement arrangement. Department of Labor guidance specifically notes that federal, state and local government plans and some church plans are not covered.

If you are unsure whether ERISA applies, review the Summary Plan Description and ask the plan administrator. EBSA can also help you understand whether the federal rules it enforces apply to your situation.

What if the appeal is denied again?

Department of Labor guidance states that a participant may have a right to sue a plan and its fiduciaries under ERISA to recover benefits due or clarify rights to future benefits. Normally, you should follow and exhaust the plan's required claims review process before challenging a benefit denial in court.

The final adverse decision should describe your right to seek judicial review. Court filing deadlines can depend on the plan terms, the claim and applicable law, so do not infer a lawsuit deadline from the plan's 60-day internal appeal period. If you are considering litigation after a final denial, obtaining legal advice promptly can help you identify the deadline that applies to your specific claim.

Common mistakes to avoid

• Do not miss the plan's appeal deadline. For an ordinary ERISA retirement benefit claim, the federal minimum opportunity to request review is generally 60 days after receiving the denial.
• Do not send the appeal to an office simply because it is your employer's human resources department. Follow the recipient and submission instructions in the plan's claims procedure or denial notice.
• Do not appeal without addressing the specific reasons and plan provisions cited in the denial.
• Do not assume the initial claim file contains every fact that can be considered. Submit relevant additional documents and information with the appeal.
• Do not pay a third party merely to contact EBSA. EBSA Benefits Advisors provide federal assistance directly.
• Do not confuse an employer retirement plan claim with Social Security retirement, unemployment benefits or another government benefit process.