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Prepared by the U.S. Department of Labor
Chapter 6: Making a Benefits Claim And Filing Suit Under ERISA
This chapter outlines how and under what circumstances you can make a
benefits claim. It tells you what appeal procedures to follow if your
claim for benefits is denied, and describes your rights to pursue a
lawsuit. The following questions are addressed:
- How Do You Make A Claim For Benefits?
- May You Sue Under ERISA?
- What Is The Role Of The Department Of Labor If You Sue Under ERISA?
- May Your Employer Fire You For Asserting Your Rights Under ERISA?
Under ERISA you have a right to make a claim for benefits due under a
plan. ERISA requires all plans to have a reasonable written procedure for
processing your claims for benefits and for appealing if your claim is
denied. The summary plan description (see Chapter 2) should contain a
description of your plan s claims procedure. If you believe you are
entitled to a benefit from a pension plan, but your plan fails to set up a
claims procedure, you may present the claim to the plan administrator.
If you make a claim for benefits that is denied, the plan must notify
you in writing - generally within 90 days after receipt of the claim - of
the reasons for the denial and the specific plan provisions on which the
denial is based. If the plan denies your claim because the administrator
needs more information to make a decision, the administrator must tell you
what information is needed. Any notice of denial must also tell you how to
file an appeal. If special circumstances require your plan to take more
time to examine your request, it must tell you within 90 days that
additional time is needed, why it is needed, an d the date by which the
plan expects to make a final decision. If you receive no answer at all in
90 days, this is treated the same as a denial, and you can proceed to
appeal.
You must be allowed at least 60 days to appeal any denial. After
receiving your appeal, the plan generally must issue a ruling within 60
days, unless the plan provides for a special hearing. If the plan notifies
you that it must hold a hearing, or that it has other special
circumstances, it may have an additional 60 days.
The plan must furnish you with the final decision on your appeal and
the reasons for the precision with references to the relevant plan
documents. If you disagree with the final decision, you may then file a
lawsuit seeking your benefit under ARISE, as explained below. But courts
generally require that you complete all the steps available to you under
the claims procedure in a timely manner before you seek relief through a
lawsuit. This is called "exhausting your administrative remedies."
As a plan participant or beneficiary, you may bring a civil action in court to:
- Recover benefits due you and enforce your rights under the plan.
- Get access to plan documents you requested in writing. If your plan administrator does not supply the plan documents within 30 days of your written request, a court could find the plan administrator personally liable for up to $100 per day (unless the failure results from circumstances reasonably beyond his or her control).
- Clarify your right to future benefits.
- Get appropriate relief from a breach of fiduciary duty.
- Enjoin any act or practice that violates the terms of the plan or any provision of Title I of ERISA, such as the reporting and disclosure, participation, vesting or funding, and fiduciary provisions, or to obtain other equitable relief.
- Enforce the right to receive a statement of vested benefits upon termination of employment.
- Obtain review of a final action of the Secretary of Labor, to restrain the Secretary from taking action contrary to ARISE, or to compel the Secretary to take action.
- Obtain review of any action of the PBGC or its agents that adversely affects you.
You may file your lawsuit under ERISA in a federal district court. If
you seek benefits or clarification of your right to future benefits, you
may file an alternative suit in a state court. The court in its discretion
may order either party in the suit (you or the plan/plan fiduciaries/plan
sponsor) to pay reasonable attorney fees and costs, when a participant or
beneficiary sues under ERISA.
The Secretary of Labor may directly bring a civil action under ERISA to
enforce the fiduciary duty provisions of ERISA. The Secretary also has
limited authority to bring a civil action to enforce ERISA's
participation, vesting, and funding standards with respect to a
tax-qualified plan. In addition, the Secretary of Labor has discretion to
intervene in lawsuits filed in federal court to enforce rights under
ERISA. A participant or beneficiary who brings an action in federal court
claiming a breach of fiduciary duty must provide a copy of the complaint
to the Secretary of Labor and the Secretary of the Treasury by certified
mail. It is not necessary to provide such notice to any government agency
if you bring a lawsuit solely to recover benefits under the plan.
ERISA prohibits employers from promising pensions and then firing or
disciplining workers to avoid paying a pension. To that end, ERISA says it
is unlawful for an employer to discharge, fine, suspend, expel,
discipline, or discriminate against you or any beneficiary for the purpose
of interfering with the attainment of any right to which you may become
entitled under the plan or the law.
Also, employers cannot take any of these steps against you for
exercising any of your rights or prospective rights under a plan or ERISA,
or for giving information or testimony in any inquiry or proceeding
relating to ERISA. Moreover, the use of force or violence to retrain,
coerce, or intimidate you for the purpose of interfering with your rights
or prospective rights, is punishable by a fine of up to $10,000 and/or up
to one year in prison.
THE TEXT ABOVE IS PUBLIC DOMAIN MATERIAL AUTHORED BY AN AGENCY OF
THE UNITED STATES GOVERNMENT AND NOT COPYRIGHTED BY THIS WEBSITE.
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