ERISA quick-start (5 cues): - W‑2 Box 12 Code C: Email payroll to request prior W‑2s showing Code C (imputed income for group-term life >$50k) - SPD: Request the current Summary Plan Description from the plan administrator - Certificate of Insurance: Request the group life COI/policy booklet (including riders/amendments) - Form 5500 lookup: Ask HR to confirm plan number/EIN and share the latest 5500 (or search the DOL’s EFAST2 Filing Search) - Waiver‑of‑Premium: Request WOP (disability) claim form, proof standards, and deadlines

Introduction

Employer group life insurance provided by private-sector employers is generally an ERISA-covered “employee welfare benefit plan.” That means plan terms control, state-law remedies are largely preempted, and claims/appeals must follow ERISA’s procedural rules. Governmental plans (including the federal FEGLI program) are excluded from ERISA and follow different rules.

What an SPD must tell you—and why to start there

The Summary Plan Description (SPD) is the controlling plain‑language document for participants/beneficiaries. For welfare plans (including group life), the SPD must include: plan administrator contact details; plan/EIN/plan number; eligibility and benefit descriptions; circumstances causing loss or denial of benefits; and the plan’s claims and appeals procedures with applicable time limits. Ask the plan administrator (often HR/Benefits) for the current SPD and any separate “certificate of insurance” (COI) issued by the insurer.

• If the SPD is missing, request it in writing. ERISA requires administrators to furnish plan documents upon written request; civil penalties under ERISA §502(c)(1) may apply for failures, with dollar amounts adjusted annually for inflation.

• Keep your request, delivery proof, and any responses. These records matter if you need to escalate a claim.

SPD‑driven claims steps (ERISA life insurance)

Follow the SPD’s instructions precisely—deadlines and where/how to file control your rights.

1) Identify the proper “claimant.” For death benefits, that’s the named beneficiary; for ancillary benefits (e.g., conversion, accidental death, or disability waiver‑of‑premium), the SPD defines who may claim. 2) File the initial claim where the SPD directs (plan administrator or insurer/claims fiduciary). For non‑health, non‑disability welfare claims (like life insurance), a benefit determination is generally due within a reasonable period, not later than 90 days after receipt, with one 90‑day extension for special circumstances. Adverse decisions must explain reasons and the appeal process. 3) Appeal on time. ERISA requires a “full and fair review.” Most welfare plans must decide appeals within 60 days (extensions allowed in limited circumstances; committee/board timelines may apply). Your denial letter and SPD state exact timeframes and where to send the appeal. 4) Preserve the “administrative record.” Submit all evidence (e.g., payroll deductions, EOI approval, enrollment confirmations) during the appeal; courts typically review the record as it existed when the plan decided the appeal.

How to look up a plan using Form 5500 (EFAST2)

Form 5500 filings identify the plan sponsor, plan number, and some administrative contacts. Use the DOL’s public EFAST2 Filing Search:

• Go to the DOL’s Form 5500 page and open the “Form 5500 Filing Search.”

• Search by employer name, EIN, or plan number. Download the latest filing and attachments (e.g., Schedule A for insured benefits naming the carrier).

• Use the sponsor address/contact to direct SPD/records requests or confirm the correct claims address.

Quick identifiers table

W‑2 Box 12 Code C as a clue to employer group life

W‑2 Box 12 Code C means the employer reported taxable cost of group‑term life insurance over $50,000 (imputed income). Its presence on prior W‑2s is a strong indicator the employee had employer‑provided group life coverage at that time. It is not proof that coverage existed on the date of death—verify eligibility, effective dates, and any required Evidence of Insurability (EOI) in the SPD/COI.

Evidence of Insurability (EOI): approvals, denials, and missing paperwork

Many plans require EOI for late enrollment or amounts above the “guaranteed issue” limit. If EOI was required but never obtained/approved, the insurer may deny supplemental coverage; however, federal enforcement and litigation frequently focus on fiduciary failures in enrollment/EOI administration (e.g., taking premiums without obtaining/confirming required EOI). Gather enrollment confirmations, EOI submissions/approvals, and payroll deductions to support your claim or appeal.

Helpful definitional guidance on how employers administer EOI and when it’s required in group settings can also be found in university HR benefit explanations. While plan terms control, these resources reflect common market practices.

Waiver‑of‑Premium (WOP) = a disability benefit under ERISA

If the plan conditions a premium waiver (continuing life coverage without premiums) on proof of disability, the claim is treated as a “disability claim” under ERISA’s claims‑procedure rule. Disability claims have stricter timelines and content requirements for denial letters. Review the SPD/COI for definitions, proof standards, and deadlines. Industry‑wide uniform standards show typical triggers, but your plan governs.

FEGLI vs. ERISA: different rules, different process

• Federal employees/retirees are covered by FEGLI (a federal program), not ERISA. Claims go to the Office of Federal Employees’ Group Life Insurance (OFEGLI), administered by MetLife, following OPM instructions and using FE-6/FE‑6 DEP forms. Use the OPM FEGLI pages for reporting a death, claim forms, and status checks; OFEGLI contact details are published by OPM and MetLife.

• ERISA doesn’t apply to governmental plans, including FEGLI. If you’re unsure whether a decedent’s plan is ERISA or governmental, check the employer type and the SPD/5500.

One‑page How‑To: file an employer group life claim (ERISA)

1) Collect documents: death certificate, SPD/COI, any enrollment/beneficiary forms, prior W‑2s (check Box 12 Code C), and pay stubs showing premium deductions. 2) Confirm the plan/insurer and claim address from the SPD or EFAST2 Form 5500 materials; if needed, send a written SPD request to the plan administrator. 3) Submit the initial claim with all required proofs. Diary the 90‑day decision deadline (plus any disclosed extension) and keep proof of submission. 4) If denied, request the complete claim file and appeal by the SPD deadline. Include evidence (e.g., EOI approval, payroll records, HR emails). 5) For disability‑based WOP disputes, apply ERISA’s disability‑claim timelines and content rules to the appeal. 6) If you still disagree after final denial, discuss remedies under ERISA §502(a) with counsel. Keep all records.

FAQ

• Does ERISA preempt state “bad faith” insurance remedies for employer group life? Generally yes; ERISA broadly preempts state laws “relating to” ERISA plans, with a narrow savings clause for laws that regulate insurance—but ERISA’s remedies still control claims for benefits.

• Can Form 5500 prove coverage? It identifies the plan and often the insurer/contract via Schedule A, but eligibility/effective dates come from the SPD/COI and the claim record.

• What if the employer took premiums but never submitted/obtained required EOI? Gather proof of deductions and enrollment; recent DOL actions highlight fiduciary duties around EOI and eligibility. Raise these issues in your appeal.

• Is there a penalty if the plan won’t send the SPD? ERISA allows civil penalties for failure to furnish plan documents upon written request; amounts are inflation‑adjusted annually. Cite §502(c)(1) in your letter.

• Where do FEGLI claims go? OFEGLI (MetLife) processes FEGLI claims; follow OPM’s FE‑6/FE‑6 DEP instructions and use OFEGLI’s mail/fax/contact points.

Where Sunset fits

If you need help locating possible life insurance (including employer group coverage) and managing claim paperwork, Sunset’s free tool can search for policies and help you submit claims. See Sunset’s dedicated life insurance search. (Note: This page provides general information, not legal advice.)