ERISA Disability Claims for Eating Disorder Treatment
Author: Ian C. Langtree - Writer/Editor for Disabled World (DW)
Published: 2015/02/04 - Updated: 2026/01/11
Publication Type: Informative
Category Topic: Insurance - Related Publications
Page Content: Synopsis - Introduction - Main - Insights, Updates
Synopsis: This information provides practical guidance from disability law specialists on successfully managing ERISA-regulated disability insurance claims when seeking coverage for eating disorder treatment. The piece addresses a critical gap many families face when insurance companies deny claims by labeling treatment as medically unnecessary. The content proves valuable because it walks readers through the appeals process, warns about common insurance company tactics designed to discourage claims, and stresses the importance of building a complete administrative record before the claim file closes - advice that can mean the difference between receiving essential treatment coverage and bearing catastrophic out-of-pocket costs. People dealing with eating disorders, their families, and those facing similar mental health coverage denials will find actionable steps to protect their rights under employee benefit plans - Disabled World (DW).
- Definition: Employee Retirement Income Security Act (ERISA)
ERISA, the Employee Retirement Income Security Act of 1974, is federal legislation that governs most employer-sponsored benefit plans in the United States, including pension plans, health insurance, and disability coverage. Congress passed this law to protect workers after several high-profile cases where employees lost their promised retirement benefits due to corporate mismanagement and fraud. The law sets minimum standards for these plans, requires detailed disclosure of plan information to participants, establishes fiduciary responsibilities for those who manage plan assets, and creates a uniform system of enforcement through federal courts rather than state courts. What makes ERISA particularly significant for people with disabilities is that it preempts state insurance laws, meaning workers who receive benefits through their employer face different rules and often fewer protections than those who buy individual policies. Under ERISA, claimants cannot sue for punitive damages, cannot demand a jury trial, and must exhaust the plan's internal appeal process before going to court - restrictions that have made these cases notoriously difficult to win without experienced legal representation.
Introduction
Dealing with ERISA When it Comes to Eating Disorders
2015 marks 41 years since ERISA was signed into law and it still creates a tangled web for those with mental and physical disabilities. The Employee Retirement Income Security Act (ERISA) is a complex statute that regulates employee benefits such as pensions, life, health, and disability insurance plans.
Main Content
Policyholders can find it challenging not only to file a claim but also to learn about the process to handle denied claims with these insurance policies. The steps to appeal a denied claim are similar for the various types of insurance.
It is particularly important to gather any and all relevant and send copies to the insurance company:
"The reason it is especially important to 'get it right' is that under ERISA, if your denial is upheld on appeal and you still disagree with the decision, the administrative record/claim file is 'closed' and you are not allowed to submit new information except in rare circumstances. Consequently, any Court that reviews the claim decision will typically be limited only to the claim file in front of the appeals examiner," (Disability Insurance Claims: Massachusetts CFIDS/ME & FM Association, January 13, 2015).
Employers do not necessarily have to participate in offering benefit plans to their employees but if they do, they must meet the minimum requirements stated in the ERISA statute and regulations.
As many policyholders know, a denied claim can be stressful and countless people don't know what procedure to follow to appeal. For health issues, such as eating disorders, most insurance companies will not see certain treatments as medically necessary, therefore denying any claims they receive.
When policyholders know the appeals process with the insurance company and with ERISA, they will have a much better chance of a positive outcome. Thankfully, there are many talented individuals out there who are able to advise patients and families about the rules to follow in order to get the coverage they rightfully deserve.
"The insurance company is going to do whatever they can to keep you from following through on a denied claim," states Lisa S. Kantor, founding partner of Kantor & Kantor, LLP and leading expert in eating disorder claims.
"They will place obstacles in your way like deliberately misinterpreting your requests for your insurance documents. Their hope is to mislead and confuse you so that you will not continue your quest to appeal the denied claim. I encourage you to find a lawyer who is knowledgeable in both ERISA and eating disorders for help in managing this overwhelming process. There are people out there who want to help so don't lose hope!"
ERISA is a complicated topic with many gray areas. Policyholders shouldn't have to fight this battle on their own. With complicated health issues pertaining to eating disorders, the conflict is doubly tough, leaving many sick with no way to pay for treatment. Individuals and their families are urged to get in touch with an experienced lawyer today so that they can begin looking to a happier future.
Insights, Analysis, and Developments
Editorial Note: The disconnect between medical necessity and insurance approval remains one of the most frustrating barriers in disability law, particularly for conditions like eating disorders where treatment costs can exceed what most families can afford independently. While ERISA was designed to protect employee benefits, its administrative closure rules create a high-stakes, one-shot scenario where policyholders must get their appeals exactly right the first time or lose the chance to present crucial evidence in court. This makes specialized legal counsel not just helpful but often essential, transforming what should be a straightforward medical coverage question into a complex legal battle that sick individuals are least equipped to fight alone - Disabled World (DW).
Author Credentials: Ian is the founder and Editor-in-Chief of Disabled World, a leading resource for news and information on disability issues. With a global perspective shaped by years of travel and lived experience, Ian is a committed proponent of the Social Model of Disability-a transformative framework developed by disabled activists in the 1970s that emphasizes dismantling societal barriers rather than focusing solely on individual impairments. His work reflects a deep commitment to disability rights, accessibility, and social inclusion. To learn more about Ian's background, expertise, and accomplishments, visit his full biography.