UnitedHealthcare ERISA Appeal Process: Complete Guide

Updated January 2024 • 10 min read

If you have UnitedHealthcare through your employer, your health plan is governed by ERISA (Employee Retirement Income Security Act)—a federal law that provides important procedural protections UHC must follow.

This guide explains exactly how to use ERISA to your advantage when appealing a UHC denial.

Is Your Plan ERISA-Covered?

ERISA Plans Include:

✅ Employer-sponsored group health insurance
✅ Union health plans
✅ Multi-employer plans
✅ Self-funded employer plans (even if administered by UHC)

NOT ERISA Plans:

❌ Individual/family marketplace plans
❌ Medicare or Medicare Advantage
❌ Medicaid
❌ Government employee plans (federal, state, local)
❌ Church plans (unless they elected ERISA coverage)

How to confirm: Ask your HR department or look for "ERISA" in your Summary Plan Description (SPD). UHC must provide the SPD upon request.

Why ERISA Matters: Your Federal Rights

ERISA provides stronger procedural protections than state insurance laws. UHC must:

Strict Timelines

Pre-service (prior auth): 15 days to decide (can extend 15 days with notice)
Concurrent care reduction: Sufficient time to appeal before reduction
Post-service: 30 days to decide
Urgent care: 72 hours to decide

If UHC misses these deadlines, they must approve your claim.

Full and Fair Review

Must provide specific reasons for denial
Cannot use new reasons during appeal
Must allow you to review your complete file
Cannot rely on initial decision reviewer

Right to Information

Complete denial letter with specific policy/criteria cited
Access to all documents UHC considered
Right to submit written comments and documents
Free copy of internal rules/guidelines/criteria

Prohibition on Conflicts of Interest

Appeal reviewer cannot be supervised by initial decision-maker
Cannot be hired specifically to deny claims
For medical judgments, must consult appropriate health care professional

Step-by-Step: ERISA Appeal Process

Step 1: Review Your Denial Letter (Day 1)

UHC's ERISA denial letter must include:

Specific reason(s) for denial
Reference to specific plan provision(s)
Description of additional material needed (if any)
Explanation of appeal process
Statement about availability of external review
For medical necessity denials: clinical rationale

Red Flag: Deficient Denial Letter

If UHC's letter is missing required elements, document this ERISA violation. It strengthens your appeal and potential legal case.

What to do: Point out the deficiency in your appeal letter and file a DOL complaint.

Step 2: Request Your Complete File (Days 1-7)

You have the right to review all documents UHC relied on for the denial. Send this request:

To: UnitedHealthcare Appeals Department

Re: [Your name, ID number, claim number]

Pursuant to ERISA Section 503 and 29 CFR §2560.503-1, I request immediate access to:

All documents, records, and other information relevant to my claim
The specific medical policy/guideline used to deny my claim
Any internal rules, guidelines, protocols, or criteria relied upon
All medical records and physician reviewer notes
Complete Summary Plan Description

Please provide these materials within 30 days as required by ERISA.

[Your signature]

Send via certified mail and keep proof of delivery.

Step 3: Gather Supporting Evidence (Days 7-30)

While waiting for UHC's file, collect:

Medical Evidence

Physician letter: Detailed medical justification addressing denial reason
Medical records: All relevant treatment notes, test results, imaging
Clinical guidelines: NCCN, medical society guidelines supporting treatment
Peer-reviewed literature: Studies demonstrating efficacy
Failed alternatives: Documentation of treatments tried before denied service

Plan Documents

Summary Plan Description (SPD)
Certificate of Coverage
Evidence of Coverage booklet
Any plan amendments

Procedural Documentation

Timeline of events (dates, times, people contacted)
All correspondence with UHC
Denial letters and Explanation of Benefits
Prior authorization requests/denials

Step 4: Analyze UHC's Medical Policy (Days 30-45)

When you receive UHC's medical policy that was used to deny your claim:

Read it carefully: Understand exact criteria for coverage
Identify how you meet criteria: Match your case to each requirement
Find misapplication: Where did UHC misinterpret policy?
Check for plan conflict: Does the medical policy conflict with your plan document? (Plan wins if conflict)

Pro Tip: Medical Policy vs. Plan Document

UHC's internal medical policies cannot override your plan document. If your SPD says a service is covered, UHC cannot deny it based on an internal guideline that's more restrictive.

Example: SPD covers "medically necessary" treatment. UHC medical policy adds requirements not in SPD. Argue UHC policy illegally narrows coverage.

Step 5: Write Your Appeal Letter (Days 45-60)

Your ERISA appeal letter should include:

I. Header Information

Your name, address, member ID
Claim number and denial date
Patient name (if different)
Reference to ERISA rights

II. Statement of Appeal

"Pursuant to ERISA Section 503 and 29 CFR §2560.503-1, I appeal the denial of [service/claim] dated [date]."

III. Factual Background

Your medical condition/diagnosis
Treatments tried and failed
Why denied treatment is necessary
How denial affects your health

IV. Why Denial is Wrong

Plan coverage: Show SPD covers this service
Medical necessity: Physician letter + medical evidence
Clinical guidelines: NCCN, society guidelines support treatment
UHC criteria met: Address each element of UHC's medical policy
Peer-reviewed evidence: Studies showing efficacy

V. ERISA Procedural Issues (if applicable)

Deficient denial letter
Missed deadlines
Failure to provide requested documents
Conflict of interest
Use of new reasons not in original denial

VI. Supporting Documents

List all attachments by number and description

VII. Conclusion and Request

"For the reasons stated above, I request that UnitedHealthcare reverse its denial and approve coverage for [service]. I expect a written response within [30/72 hours] as required by ERISA."

Send via certified mail, return receipt requested. Keep copy for your records.

Step 6: Monitor UHC's Timeline (Days 60-90)

ERISA requires UHC to decide your appeal within:

Urgent care: 72 hours
Pre-service: 30 days
Post-service: 60 days

Deadline Violations

If UHC misses the deadline, they are deemed to have exhausted your internal appeals—meaning you can proceed directly to external review or federal court.

Action: Send letter stating: "UnitedHealthcare has failed to issue a timely decision. I consider internal appeals exhausted and will proceed to external review."

Step 7: Receive Decision (Day 90)

UHC's appeal decision must include:

Specific reasons for upholding or reversing denial
Reference to specific plan provisions
Statement of your right to external review
Information about accessing external review
For adverse decisions: clinical rationale

If approved: Congratulations! Monitor to ensure UHC actually pays.

If denied: Proceed to Step 8.

Step 8: External Review (Days 90-180)

After internal appeal denial, you have the right to independent external review:

External Review Basics

Who reviews: Independent third-party reviewer (not paid by UHC)
Cost: Free to you
Timeline: Request within 4 months of internal denial; decision in 45-60 days
Standard: De novo review (fresh look at evidence)
Binding: UHC must follow external reviewer's decision

External review process varies by state. See our state-by-state external review guide.

Common ERISA Violations by UHC

1. Using New Reasons During Appeal

ERISA rule: UHC cannot raise new reasons for denial during appeal that weren't in original denial letter.

Example: Original denial says "not medically necessary." Appeal decision says "excluded service." This violates ERISA.

Your response: Point out violation, request reversal based on procedural error, file DOL complaint.

2. Inadequate Denial Letters

ERISA rule: Denial must include specific reasons and plan provisions.

Violation examples:

"Not covered per plan" (too vague)
No reference to specific plan provision
No explanation of appeal rights
Medical necessity denial without clinical rationale

3. Missed Deadlines

ERISA rule: UHC must decide appeals within statutory timeframes.

Consequence: Automatic exhaustion of internal appeals; you can proceed directly to external review or court.

4. Failure to Provide Documents

ERISA rule: You have right to review entire file, including internal guidelines.

Violation: UHC claims guidelines are "proprietary" or delays providing them.

Your response: Cite 29 CFR §2560.503-1(m)(8); file DOL complaint.

5. Biased Reviewer

ERISA rule: Appeal reviewer cannot be supervised by initial decision-maker or have financial incentive to deny.

Red flag: Same doctor's name on denial and appeal decision; reviewer employed by claims cost-containment company.

Filing a Department of Labor Complaint

If UHC violates ERISA procedures, file a complaint with the Department of Labor (DOL):

Online: dol.gov/agencies/ebsa
Phone: 1-866-444-3272
Mail: Your regional EBSA office

Sample DOL Complaint

Subject: ERISA Violation Complaint - UnitedHealthcare

I am filing a complaint against UnitedHealthcare for violations of ERISA Section 503 and 29 CFR §2560.503-1.

Violation(s): [Describe specific violation - missed deadline, inadequate denial letter, failure to provide documents, etc.]

Impact: [Explain how violation harmed you - delayed care, prevented fair appeal, etc.]

Documentation: [List attachments - denial letters, correspondence, timeline]

I request the Department investigate this matter and take appropriate enforcement action.

When to Consider Legal Action

ERISA allows you to sue in federal court if:

You've exhausted internal appeals (or UHC violated procedure)
Claim is for significant amount ($50K+)
UHC clearly violated plan terms or ERISA procedures
You have strong medical evidence

ERISA Lawsuit Limitations

Good news: You can sue in federal court without state law limits.

Bad news: ERISA limits damages to plan benefits only—no pain and suffering, no punitive damages. Attorney fees may be awarded if you win.

Time limit: Check your plan's lawsuit deadline (often 180 days from final denial).

Finding an attorney: Look for lawyers specializing in ERISA health claims (not life insurance or pensions). Many work on contingency (paid from recovery) for large claims.

Special Issues for Self-Funded Plans

If your employer self-funds the plan (pays claims directly, UHC just administers), know that:

Plan document controls: UHC's standard policies may not apply; your employer's plan document is the governing authority
Employer discretion: Many self-funded plans give employer "discretionary authority" to interpret benefits
Appeals may go to employer: Not just UHC—check your SPD
State mandated benefits don't apply: ERISA preempts state insurance laws for self-funded plans