My Employer's Health Plan Denied My Claim: What to Do
A plain-language, step-by-step walkthrough for a denied claim on an employer health plan: read the letter, find out if the plan is self-funded, demand the documents, build the appeal, file on time, and escalate to external review. Grounded in the federal ERISA regulation.
When your employer's health plan denies a claim, work the steps in order: (1) read the denial letter and find the specific reason and the appeal deadline; (2) find out whether the plan is self-funded or fully-insured, because it decides your rights; (3) send a written demand for the full claim file and the exact criteria the plan used, your right under 29 CFR 2560.503-1(h)(2)(iii); (4) build the appeal around those criteria, ideally with a letter of medical necessity from your treating doctor; (5) file the internal appeal well before the deadline (a federal floor of at least 180 days for group health plans) with proof of filing; and (6) if it is upheld, request external review by an independent organization. The plan document and denial letter always control the specifics, and this is general information, not legal advice.
A denial from a workplace health plan can feel like a closed door, but under federal law it is the opening of a process, not the end of one. Employer plans are almost always governed by ERISA, and ERISA hands you a defined set of steps and rights: to know exactly why you were denied, to see every document and criterion the plan used, to a genuine independent re-review, and, if needed, to an outside opinion that binds the plan. The catch is that the process rewards moving deliberately and on time. This guide walks the whole path in plain language, in the order you should actually do it, so you can prepare and file your own appeal with confidence. Apellica helps people prepare, file, and track appeals; it is not a law firm or a medical provider, and nothing here is individualized legal advice.
The full path, step by step
Follow these steps in order. Each one sets up the next, the document demand, for example, is what makes the appeal itself strong.
Step 1: Read the letter and start the clock
The denial notice must, under 29 CFR 2560.503-1(g), state the specific reason for the denial and the plan provision it relies on, and describe the appeal procedure and time limits. Read it slowly and pull out five things: the date of the notice (your clock starts here), the exact reason, the claim number and dollar amount, the appeal deadline, and where and how to file.
If the reason is vague, only 'not medically necessary' with no criterion, or the letter is missing required elements, note it. A defective notice is both easier to appeal and potentially a procedural failure you can raise.
Step 2: Self-funded or fully-insured?
This one question shapes everything that follows. If your employer pays the claims and the carrier is just the administrator, the plan is self-funded and governed almost entirely by the federal ERISA regulation, with federal external review and, if it ever comes to it, a federal-court remedy. If the carrier bears the risk, the plan is fully-insured and you add your state's insurance protections and external-review program on top.
Check your Summary Plan Description for 'self-funded,' 'self-insured,' or 'administered by,' or simply ask HR in writing. The dedicated guide on telling the difference walks through five reliable checks.
Step 3: Demand the documents and criteria
This is the highest-leverage step, and most people skip it. Under 29 CFR 2560.503-1(h)(2)(iii) you can demand, free of charge, all documents, records, and information relevant to your claim, including the internal rule, guideline, or clinical criterion the plan applied. Send a short written request naming the regulation, asking for the complete claim file, and specifically requesting the medical-necessity criteria and any medical-reviewer opinions used. Keep proof of sending.
Do it early, while the appeal clock still leaves you time to build around whatever standard the plan produces. You cannot rebut a criterion you have never seen.
Steps 4-5: Build and file the appeal
With the criteria in hand, the appeal becomes a structured rebuttal: take each criterion the plan used and show, with records, how your situation meets it. The most persuasive piece is a letter of medical necessity from your treating physician that addresses each criterion in the plan's own clinical language and cites professional guidelines. A common, effective approach is to give the doctor a well-organized draft to edit and sign.
File well before the deadline, by a method that proves it landed. If the care is urgent, request expedited review, the plan must then decide as fast as the situation requires and no later than 72 hours. Put everything you want considered into the record now, because if the dispute ever reaches court, the decision is usually made on the record that existed at the final internal denial.
| Filing method | Strength | Watch out for |
|---|---|---|
| Plan online portal | Date-stamped, immediate | Confirm upload succeeded; save a screenshot |
| Certified mail, return receipt | Durable legal proof | Slower; mail several days before the deadline |
| Fax with confirmation | Same-day paper trail | Keep the confirmation sheet; queues can fail |
Step 6: External review, and where to get free help
If the internal appeal is upheld, most non-grandfathered plans owe you an external review: an independent review organization takes a fresh look, and its decision on medical-necessity, experimental/investigational, and similar denials is binding on the plan. For self-funded plans this runs through the federal external-review process; for fully-insured plans it usually runs through your state's program. It is free to you.
You do not have to do this alone. State Consumer Assistance Programs, the DOL's EBSA benefits advisors (for ERISA plans), and nonprofit patient-advocacy groups offer free help. See the guide on free help for a denied claim for where to start.
Frequently asked questions
What is the very first thing to do when my work plan denies a claim?
Read the denial letter and pull out the date (your appeal clock starts here), the specific reason, the claim number, and the appeal deadline. Then find out whether the plan is self-funded or fully-insured, because it decides which rights and processes apply.
How long do I have to appeal my employer plan's denial?
For an ERISA group health plan, at least 180 days from the date of the denial notice, under 29 CFR 2560.503-1. That is a federal minimum; your plan may allow more. The exact deadline is on your denial letter and in your Summary Plan Description.
Can I get the plan's medical-necessity criteria?
Yes. Under 29 CFR 2560.503-1(h)(2)(iii) you can request, free of charge, all documents and information relevant to your claim, including the internal criteria the plan applied. Send a written demand early so you can build the appeal around the plan's own standard.
Do I need my doctor's help to appeal?
It helps enormously. A letter of medical necessity from your treating physician, addressing each criterion the plan used in clinical language, is the single most persuasive document in most appeals. You can give the doctor an organized draft to edit and sign.
What if my internal appeal is denied?
Request external review by an independent review organization. For medical-necessity and similar denials its decision binds the plan, and it is free. Self-funded plans use the federal process; fully-insured plans typically use a state program.
Is Apellica a law firm?
No. Apellica helps patients prepare, file, and track appeals and is not a law firm or a medical provider. The information here is general, not individualized legal advice. For a lawsuit under ERISA, consult a qualified attorney.
Where can I get free help with the appeal?
State Consumer Assistance Programs, the Department of Labor's EBSA benefits advisors for ERISA plans, and nonprofit patient-advocacy organizations all offer free assistance. See the free-help guide for how to reach them.
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