The insurer says my plan is self-funded so the state cannot help. Is that true?
Usually yes for the state insurance department, because a self-funded employer plan is governed by federal ERISA rules, not state insurance law. But you are not without a regulator: the U.S. Department of Labor enforces ERISA claims rules, the plan still owes you a full and fair review with the specific reason and claim file, and external review by an independent reviewer still applies to most self-funded plans.
What to do, in order
- Step 1
Confirm the funding type
Ask HR or the plan for the Summary Plan Description; it states whether benefits are self-funded or insured. The insurer's name on the card does not settle it, because insurers administer self-funded plans too.
- Step 2
Use ERISA's own rules
The plan must state the specific reason and plan provision, give you the criteria and the claim file on request, decide appeals within 30 days pre-service or 60 days post-service, and use a qualified independent reviewer for medical judgments. Ask for each in writing.
- Step 3
External review still applies
Non-grandfathered self-funded plans must offer external review through the federal process or a contracted independent review organisation. The denial notice has to tell you how.
- Step 4
Complain to the Department of Labor
EBSA takes benefit-claim complaints and contacts the plan. Its benefits advisors are free and they are the right regulator for a self-funded plan.
The deadline that applies
At least 180 days from the denial to file the internal appeal, and four months from the final internal decision to request external review (29 CFR 2560.503-1; 45 CFR 147.136). Governmental and church plans sit outside ERISA and follow the plan document. The notice controls.
Calculate your date →Documents to gather
- The Summary Plan Description
- The denial notice with the reason and provision
- Your written request for the criteria and claim file
- The external review instructions from the notice
Go deeper
Related questions
Can the state insurance department do anything at all?
It can tell you whether the plan is insured (then it has jurisdiction) and refer you to EBSA if not. Some states also run consumer assistance programs that help with any plan type.
Does ERISA weaken my rights?
It changes the forum, not the core rights: written reasons, the claim file, deadlines, independent medical review, and external review remain.
What about a lawsuit?
ERISA allows suit after the internal appeal is exhausted or deemed exhausted; the record you build in the appeal is what the court reviews.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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