Introduction

ERISA sets strict clocks for group life insurance claims and appeals. This page translates 29 CFR 2560.503‑1 into day‑by‑day actions for beneficiaries, executors, and plan administrators, with SPD touchpoints, conversion/portability edge cases, and ready‑to‑use scripts.

What counts as an ERISA group life claim

A claim for benefits under a welfare plan that is not a group health plan or a disability claim is governed by the “general” ERISA timing rules. For group life, the plan administrator must issue a claim decision within 90 days, with a single 90‑day extension for special circumstances if timely noticed. See 29 CFR 2560.503‑1(f)(1) and (g). For appeals, the plan must allow at least 60 days to appeal and must decide the appeal within 60 days, with one 60‑day extension for special circumstances if timely noticed. See 29 CFR 2560.503‑1(h)(2)(i) and (i)(1)(i). Authoritative texts: the regulation itself and U.S. DOL compliance guidance. 29 CFR 2560.503‑1 (full text) and DOL EBSA claims procedure guidance.

Day‑by‑day claims and appeals clocks

The table below assumes a typical insured group life plan (not disability; not group health). “Plan” refers to the ERISA plan (often insured and administered by the carrier). Deadlines are outside dates; earlier decisions are permitted.

Notes on tolling: The regulation expressly tolls certain timelines when additional information is requested only for group health pre‑/post‑service claims and disability claims. That tolling language does not apply to the general 90‑day life claim rule in 29 CFR 2560.503‑1(f)(1). See 29 CFR 2560.503‑1(f)(4).

Where the SPD controls (and what must be in it)

• Your Summary Plan Description (SPD) must include the plan’s claims and appeals procedures, applicable time limits, and remedies for denied claims. Plans may deliver claims procedures as a separate document if the SPD clearly says so. See 29 CFR 2520.102‑3(s) and LII text.

• The SPD must identify the plan administrator and where to send claims/appeals. See 29 CFR 2520.102‑3. The plan administrator is often the employer; the insurer may act as claims fiduciary.

• If the plan fails to establish or follow reasonable procedures, you generally need not continue with internal appeals and may sue under ERISA §502(a). See 29 CFR 2560.503‑1(l) and DOL guidance linked above.

Conversion and portability edge cases (group life)

Many group life certificates provide:

• Conversion: Right to convert all or part of terminated/reduced group life to an individual policy without evidence of insurability if the insurer receives your application and premium within at least 31 days after group coverage ends. If death occurs during that 31‑day conversion period, the death benefit is typically payable even if you did not apply. See Interstate Insurance Product Regulation Commission model standards, e.g., Group Term Life Policy Standards (conversion period “at least 31 days,” death within conversion period payable) and notice/extension mechanics.

• Notice extensions: Model standards often extend the practical conversion window when required notices are late (e.g., up to 60 days beyond the conversion period after notice). See the Insurance Compact standards cited above.

• Portability vs. conversion: Portability generally continues group coverage (often term) and may retain some riders; conversion generally issues a new individual policy (often whole life) at individual rates and typically excludes certain riders. For a practical comparison, see Penn State HR’s conversion vs. portability explainer (illustrative; your certificate controls).

• Federal examples: While not ERISA‑wide rules, program documents like FEGLI reflect common market mechanics (31‑day extension of coverage; conversion effective after the extension). See Federal Register FEGLI rules.

Practical tip: If employment or eligibility ends, calendar the 31‑day conversion/portability deadlines and preserve proof that required notices were (or were not) sent. If a death occurs near termination of coverage, evaluate the “death during conversion period” clause immediately.

Beneficiary designations and divorce (plan documents rule)

ERISA generally requires administrators to pay benefits in accordance with plan documents. State “revocation‑on‑divorce” statutes are pre‑empted for ERISA plans. If a participant fails to update the beneficiary after divorce, the named beneficiary may still take. See Egelhoff v. Egelhoff, 532 U.S. 141 (2001) (state revocation statute pre‑empted) and Kennedy v. Plan Administrator for DuPont, 555 U.S. 285 (2009) (plan documents rule governs notwithstanding divorce decree not meeting QDRO requirements).

What to include in an initial group life claim

• Certified death certificate.

• Employer/plan administrator statement confirming coverage, last day worked, class, amount, any AD&D riders, and premium status.

• Beneficiary designation(s) and any change forms; enrollment forms; SPD and certificate.

• Evidence relevant to edge cases: termination/COBRA letters, conversion/portability notices, payroll records, leave status, waiver‑of‑premium (disability) determinations, accident/medical examiner reports for AD&D.

Appeal checklist (60‑day minimum window)

Compliance quick‑reference (29 CFR 2560.503‑1)

• Initial claim decision: due as soon as reasonably possible and no later than 90 days; one written extension (up to 90 more days) permitted only if sent before day 90, describing special circumstances and a decision date. See 29 CFR 2560.503‑1(f)(1).

• Appeal filing window: at least 60 days from receipt of the denial (check your SPD for longer deadlines). See 29 CFR 2560.503‑1(h)(2)(i).

• Appeal decision: due within 60 days; one written extension (up to 60 more days) permitted if sent before day 60, describing special circumstances and a decision date. See 29 CFR 2560.503‑1(i)(1)(i).

• Missed deadlines or procedural failures: you are generally deemed to have exhausted internal remedies and may proceed to court. See 29 CFR 2560.503‑1(l) and DOL FAQ Q‑F2.

• Tolling note: explicit tolling in 2560.503‑1(f)(4) applies to group health pre/post‑service and disability claims, not to the general life‑claim 90‑day rule.

Ready‑copy appeal letter template (paste, fill brackets, send)

[Your Name]
[Address]
[City, State ZIP]
[Phone] | [Email]

[Date]

Appeals Department
[Plan Name / Plan Number]
[Insurer/Claims Fiduciary Name]
[Address]

Re: ERISA Appeal of Adverse Benefit Determination
Claimant/Decedent: [Name] | Policy/Group: [ID] | Claim #: [#]
Date of Denial (ABD): [MM/DD/YYYY]

To Whom It May Concern:

I hereby appeal the adverse benefit determination issued on [date] regarding the group life insurance claim for [decedent]. This is a timely appeal under 29 CFR 2560.503‑1(h).

Request for claim file and relevant documents
Please provide, at no charge, the complete claim file and all “relevant” documents, records, policies/certificates, guidelines, administrative procedures, internal notes/logs, and any statements of additional material or information necessary to perfect the claim. See 29 CFR 2560.503‑1(h)(2)(iii).

Standard, reasons, and evidence
The denial cites: [quote or summarize each reason]. I dispute these for the following reasons, with citations to the policy and record:
1) [Reason #1 rebuttal with page/section cites]
2) [Reason #2 rebuttal]
3) [Add as needed]

I am enclosing the following additional evidence: [list documents: beneficiary forms, employer statement, payroll/coverage records, conversion/portability notices, medical/coroner reports for AD&D, affidavits, etc.]

Procedural rights and timeline
Please confirm the appeal decision date. Under 29 CFR 2560.503‑1(i)(1)(i), a decision is due within 60 days of this appeal. Any extension must be noticed in writing before day 60, describe the special circumstances, and specify the new decision date. If the plan fails to follow ERISA claims‑procedure requirements, I understand internal remedies are deemed exhausted. See 29 CFR 2560.503‑1(l).

Relief requested
Please reverse the denial and approve benefits of $[amount] plus any applicable interest. If you decline to reverse, please provide a final written decision that includes the specific reasons, plan provisions relied upon, information needed to perfect the claim, and notice of further rights.

Sincerely,

[Your Name]
[Relationship to Decedent]
[Attachments]

• Request the entire claim file and “relevant” documents free of charge (policies, guidelines, notes, logs). See 29 CFR 2560.503‑1(h)(2)(iii).

• Identify every reason in the denial and rebut each with citations to the policy/record.

• Submit any missing forms (e.g., employer statement), affidavits on beneficiary intent (if relevant), payroll and HR records, and medical/coroner documentation for AD&D disputes.

• Preserve evidence of late notices or missed deadlines (supports deemed‑exhaustion under 29 CFR 2560.503‑1(l)).

Scripts you can use

Use and adapt as needed. Replace bracketed items.

• To HR/Plan Administrator (coverage verification)

• “Hello, I’m [name], the [beneficiary/executor] for [decedent]. Please confirm in writing: (1) the ERISA plan name and plan number, (2) the plan administrator and claims fiduciary, (3) whether group life coverage was in force on [date of death], (4) coverage amount and class, (5) any AD&D/waiver‑of‑premium riders, and (6) where to send claims and appeals. Please also provide the SPD and certificate at no charge. Thank you.”

• To Insurer (claim status and deadlines)

• “Hello, I’m following up on Claim #[number] for [decedent]. The claim was received on [date]. Under 29 CFR 2560.503‑1(f)(1), the plan must decide within 90 days unless a written extension is sent before Day 90, identifying special circumstances and a decision date. Please confirm your target decision date or send the required extension notice.”

• To Insurer (appeal and file request)

• “I appeal the adverse benefit determination dated [date]. Please acknowledge receipt and provide the complete claim file and all documents, records, rules, and guidelines relevant to the claim at no charge, per 29 CFR 2560.503‑1(h)(2)(iii). I will submit additional evidence within my appeal window.”

• To HR (conversion/portability after coverage ends)

• “Please confirm whether conversion or portability rights applied when [participant]’s coverage ended on [date], and provide proof and dates of any required conversion/portability notices. Note that many certificates provide at least a 31‑day conversion period and require written notice; late notice can extend rights. Please send the certificate language.”

Common denial themes to address on appeal

• Coverage not in force (missed premiums, ineligible class, post‑termination): obtain payroll/HR proofs; analyze conversion/portability and “death during conversion period” clauses (see Insurance Compact standards linked above).

• Beneficiary disputes (competing claims, outdated designations): plan documents govern per Egelhoff/Kennedy.

• AD&D exclusions (illness, intoxication, crime): scrutinize accident report, toxicology, and policy definitions; supply counter‑evidence.

• Waiver‑of‑premium for disability not approved: confirm disability standards and dates; gather medical and SSDI records.

How Sunset can help locate and claim policies

If you are unsure whether a group or employer‑provided life policy exists, you can run a no‑cost search and, if desired, have claims submitted and followed up on your behalf. See Sunset’s life insurance search and claims support (free to families; SOC 2 Type II; typical insurer verification in 2–3 business days once documents are submitted, per that page).

Frequently asked questions (human‑readable)

• How long does a plan have to decide a group life claim? Up to 90 days, with one 90‑day extension if properly noticed. 29 CFR 2560.503‑1(f)(1).

• How long do I have to appeal? At least 60 days from receipt of the denial, unless the SPD gives more. 29 CFR 2560.503‑1(h)(2)(i).

• Does the clock pause if the insurer asks me for more information? The regulation’s explicit tolling language applies to group health pre/post‑service and disability claims, not the general 90‑day rule for life claims. See 29 CFR 2560.503‑1(f)(4).

• What if the plan misses a deadline? You are typically deemed to have exhausted internal remedies and may file suit. 29 CFR 2560.503‑1(l); DOL FAQ Q‑F2.

• Where do I find the rules? Your SPD must describe claims/appeals procedures and timelines. 29 CFR 2520.102‑3(s).

• Divorce changed everything, right? Not unless the beneficiary was changed according to plan documents (or a valid QDRO applies). See Egelhoff and Kennedy.

Structured data: FAQ schema

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