Administrative Appeal Exhaustion

If the insurer makes an "adverse benefits determination" (meaning a decision that is in some way not favorable to you - such as terminating or denying your benefits claim), ERISA regulations require that you be allowed to submit an administrative appeal to the insurer. The administrative appeal must be submitted to the insurer within a time frame that is determined by the type of benefit for which you are making a claim, and should include all information you can gather in support of your claim. The administrative appeal is VERY important because once the insurer has received you appeal, there is no other chance to submit any new information. The insurer will decide whether to stand by or reverse its original decision based on what you have submitted. If the insurer decides to stand by its original decision to deny or terminate your benefits, your only recourse is usually to bring a case in federal court.

Sometimes people ask us why they should bother with submitting the administrative appeal. Maybe you are sure the insurer will deny the appeal anyway. Or maybe you are in a hurry - administrative appeals take time and money to prepare, and you may end having to bring a lawsuit in the end anyway. Why not bypass all that hassle and go right to court?

The answer is that ERISA requires you to do all required administrative appeals before bringing a lawsuit. If you initiate a lawsuit before completing the administrative appeals, your lawsuit will be dismissed without being heard. While there are a few exceptions to this rule, generally you must submit all required administrative appeal process before going to court.

If you have questions about administrative appeals, you can contact us at the Law Office of Katherine L. MacKinnon for a consultation on your case.