Understanding ERISA: Protecting Your Right to Coverage and Care

What Is ERISA?

ERISA stands for the Employee Retirement Income Security Act of 1974, a federal law that governs most employer-sponsored health insurance plans in the U.S. If you or your spouse get insurance through work, chances are it’s an ERISA-regulated plan.

ERISA requires your insurance plan to operate fairly, transparently, and in accordance with its own rules. That means if your surgery is denied, you have a federally protected right to appeal—and the plan must follow specific procedures when reviewing your case.

What ERISA Requires

ERISA plans must:

  • Provide a complete, accurate Summary Plan Description (SPD) upon request
  • Review appeals using qualified medical professionals in the same specialty as the treating provider
  • Explain denials using specific plan language—not vague “medical necessity” claims
  • Avoid conflicts of interest, such as having the same reviewer deny both your initial claim and your appeal
  • Adhere to strict timelines for appeal responses (typically 30–60 days)
  • Disclose the methodology for determining out-of-network reimbursement amounts if requested

If your insurance doesn’t follow these rules, they may be in violation of federal law.

Common ERISA Violations

Patients are often denied or underpaid due to errors like:

  • “Medical reviewers” who aren’t licensed in the right specialty
  • No explanation of how out-of-network reimbursement was calculated
  • No response to SPD or fee schedule requests
  • Appeals handled by the same reviewer as the original denial
  • Denials that don’t cite any language from your actual plan

If any of these apply to you, you may have a strong case for reversal—and even grounds for filing a Department of Labor complaint.

What You Can Do

  1. Request your Summary Plan Description (SPD) from your HR department or plan administrator.
  2. Ask for the reimbursement methodology if you were denied based on out-of-network pricing.
  3. Review your denial letter and check for proper citations and reviewer credentials.
  4. Appeal—formally and thoroughly. Use ERISA language, cite the SPD, and escalate if needed.
  5. File a complaint with the Department of Labor if your rights are violated. (We can help with this.)

How I Help

I specialize in turning insurance denials into approvals by holding plans accountable to ERISA standards. Whether you’re a patient fighting for lipedema surgery or a provider seeking reimbursement, I can help you:

  • Translate and interpret your SPD
  • Identify ERISA violations
  • Draft legally compliant appeals
  • Prepare complaints for the Department of Labor
  • Recover improperly denied or underpaid claims

Want to Learn More?

Grab the free ERISA Complaint Builder Worksheet or SPD Terms Glossary on our Resources page, or book a call to talk through your specific situation.