Why We Fight. When your health is on the line and your insurance company says “no,” you deserve a process that values your life as much as your plan values its bottom line. That’s why we focus exclusively on appealing denied healthcare claims under ERISA—the federal law that governs most employer-sponsored health insurance plans. Our goal is simple: to help you secure the care you need by building a strong, timely, and legally sound appeal that holds your insurer accountable.
What We Do. We don’t dabble in healthcare appeals—we dedicate our practice to them. With deep experience navigating ERISA’s complex procedural rules, we know how to build an administrative record that positions your case for success during the appeal—and in federal court, if necessary. Our role is to take the burden off your shoulders and give your appeal the urgency, clarity, and legal strength it deserves.
ERISA Appeal Timeline: Step-by-Step
The timeline below reflects a typical appeal process for an ERISA-governed health plan denial. While every case has unique facts, these are the general steps and timeframes governed by 29 C.F.R. § 2560.503-1 and related case law.
- Day 0 – Receipt of the Denial Letter
- The date of the demand letter marks the start of the clock. Your denial letter must state the reasons for denial, cite specific plan provisions, and explain your appeal rights. Under 29 C.F.R. § 2560.503-1(g), this notice must include all relevant information to prepare an appeal.
- Day 1–30 – Legal and Medical Record Review
- We review the plan documents, denial letter, Summary Plan Description (SPD), and applicable clinical guidelines.
- We also ask for your claim to file and internal insurer guidelines under your right to a “full and fair review” (29 U.S.C. § 1133).
- Our legal team collects supporting records, doctor letters, and expert opinions to rebut the denial.
- Day 30–180 – Filing the Internal Appeal
- Under ERISA, you have 180 days from the denial to submit an internal appeal (29 C.F.R. § 2560.503-1(h)(3)(i)).
- We prepare and file a comprehensive written appeal that includes:
- Factual challenges to the insurer’s reasoning
- Medical evidence proving the necessity of treatment
- Legal arguments under the plan and ERISA
- We ensure the appeal is mailed or submitted in a verifiable way.
- Insurance Company Response: 30–45 Days
- The insurer must respond within 30 days for urgent care denials or within 60 days for group health plan denials involving more complex claims.
- If they fail to respond on time, the claim may be denied, which could result in the claimant having to pursue litigation under 29 C.F.R. § 2560.503-1(l).
- Outcome and Next Steps
Appeal Approved
- The insurer reverses the denial and pays the benefit.
Appeal Denied
- We assess the case for potential litigation under 29 U.S.C. § 1132(a).
- No jury trials are allowed under ERISA; federal judges decide cases based solely on the administrative record.
- That’s why we treat your appeal like litigation from the start, carefully curating every document, medical report, and legal argument.
- If litigation is appropriate, we are ready to represent you in a federal court with more than 22 years of experience in federal litigation.
The Bottom Line
ERISA appeals are high-stakes, fast-moving, and procedurally unforgiving. There are no do-overs. That’s why every word in your appeal matters. This attention to detail is why we build your case as if it will be examined by a federal judge from day one.
If your insurance company denied your claim, don’t wait. Contact us today to start the appeal process.
Why We Fight When your health is on the line and your insurance company says “no,” you deserve a process that values your life as much as your plan values its bottom line. That’s why we focus on appealing denied healthcare claims under ERISA. It is the federal law that governs most employer-sponsored health insurance plans. Our goal is simple: to help you secure the care you need by building a strong, timely, and legally sound appeal that holds your insurer accountable.
What We Do We don’t dabble in healthcare appeals. With deep experience navigating ERISA’s complex procedural rules, we know how to build an administrative record that positions your case for success during the appeal and in federal court, if necessary. Our role is to take the burden off your shoulders and give your appeal the urgency, clarity, and legal strength it deserves.
Ethics and compliance notes for Ohio and Kentucky
Attorney Advertising. This page provides general information. It is not legal advice and does not create an attorney-client relationship. Every situation is fact-specific. Do not rely on this content without guidance from a lawyer who knows your facts. Past results do not predict future results.
Responsible lawyer and office address: Frank M. Mungo Attorney at Law, 7310 Turfway Road, Suite 550, Florence, Kentucky 41042. Mr. Mungo is licensed in Kentucky and Ohio.
