UNITED STATES DISTRICT COURT

[DISTRICT NAME] DISTRICT OF [STATE]

[PLAINTIFF NAME],

Plaintiff,

v. Civil Action No. [________________]

[DEFENDANT PLAN NAME],
[DEFENDANT INSURANCE COMPANY NAME], and
[DEFENDANT PLAN ADMINISTRATOR NAME],

Defendants.

COMPLAINT FOR BENEFITS UNDER ERISA

Plaintiff [Plaintiff Name], by and through undersigned counsel, files this Complaint against Defendants and alleges as follows:

INTRODUCTION

1. This is an action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., to recover benefits wrongfully denied under an employee benefit plan, to enforce rights under the plan, and to clarify rights to future benefits.

2. Plaintiff seeks recovery of [disability/health/life insurance/pension] benefits that were improperly denied by Defendants, together with pre-judgment interest, attorneys' fees and costs, and such other relief as the Court deems just and proper.

JURISDICTION AND VENUE

3. This Court has subject matter jurisdiction over this action pursuant to 28 U.S.C. § 1331 (federal question jurisdiction) and 29 U.S.C. § 1132(e)(1), which provides that federal district courts have jurisdiction over civil actions brought under ERISA.

4. Venue is proper in this District pursuant to 29 U.S.C. § 1132(e)(2) because:
   ☐ The Plan is administered in this District
   ☐ The breach took place in this District
   ☐ A Defendant resides or may be found in this District

5. Plaintiff has exhausted all administrative remedies available under the Plan, or alternatively, exhaustion should be excused because:
   ☐ The Plan failed to comply with ERISA's procedural requirements
   ☐ Further administrative proceedings would be futile
   ☐ The Plan failed to render a timely decision on Plaintiff's appeal

PARTIES

Plaintiff

6. Plaintiff [Plaintiff Name] is an individual residing at [Address, City, State, ZIP].

7. Plaintiff was employed by [Employer Name] from [start date] to [end date].

8. Plaintiff is a "participant" and/or "beneficiary" within the meaning of ERISA, 29 U.S.C. § 1002(7) and (8), entitled to bring this action under 29 U.S.C. § 1132(a)(1)(B).

Defendants

9. Defendant [Plan Name] is an employee benefit plan within the meaning of ERISA, 29 U.S.C. § 1002(3), and subject to ERISA's requirements.

10. Defendant [Insurance Company Name] is a corporation organized under the laws of [State of Incorporation], with its principal place of business at [Address]. [Insurance Company] issued the group insurance policy providing [type of benefits] benefits under the Plan and acts as the claims administrator and/or claims fiduciary for the Plan.

11. Defendant [Plan Administrator Name] is the plan administrator within the meaning of ERISA, 29 U.S.C. § 1002(16), responsible for the administration and operation of the Plan.

12. At all relevant times, Defendants were fiduciaries within the meaning of ERISA, 29 U.S.C. § 1002(21), and/or parties in interest within the meaning of 29 U.S.C. § 1002(14).

THE PLAN

13. The Plan is an employee welfare benefit plan within the meaning of ERISA, 29 U.S.C. § 1002(1), providing [disability/health/life insurance] benefits to eligible employees of [Employer Name] and their beneficiaries.

14. The Plan is funded through a group insurance policy, Policy Number [________________], issued by [Insurance Company Name].

15. According to the Plan documents, [describe relevant benefit provisions, definitions, and eligibility requirements].

16. The Plan provides that benefits are payable when [describe conditions for benefit payment].

FACTUAL BACKGROUND

Plaintiff's Employment and Plan Participation

17. Plaintiff was employed by [Employer Name] as a [Job Title] from [start date] to [end date].

18. Throughout Plaintiff's employment, Plaintiff was a participant in the Plan and eligible for [type of benefits] benefits.

19. Plaintiff paid premiums for coverage under the Plan [and/or] premiums were paid on Plaintiff's behalf by [Employer Name].

Plaintiff's Disability/Claim

20. On or about [date], Plaintiff became disabled and unable to work due to [describe medical condition(s)].

21. Plaintiff's disabling condition(s) include [describe diagnoses, ICD-10 codes if known].

22. As a result of Plaintiff's medical condition(s), Plaintiff is unable to perform [the material duties of their own occupation / any occupation for which they are qualified by education, training, or experience].

23. Plaintiff has received treatment from [list treating physicians and specialists], who have opined that Plaintiff is disabled and unable to work.

Initial Claim and Denial

24. On or about [date], Plaintiff submitted a claim for [type of benefits] benefits to Defendants.

25. On or about [date], Defendants denied Plaintiff's claim, stating [summarize reasons for denial].

26. The denial letter failed to [identify specific deficiencies in the denial, e.g., adequately explain the reasons for denial, identify the medical basis for the decision, identify consulting physicians, etc.].

Administrative Appeal

27. On or about [date], Plaintiff timely filed an administrative appeal of the denial, within the 180-day period provided by 29 C.F.R. § 2560.503-1.

28. In support of the appeal, Plaintiff submitted [describe additional evidence submitted, e.g., medical records, physician statements, functional capacity evaluations, etc.].

29. On or about [date], Defendants denied Plaintiff's appeal, stating [summarize reasons for appeal denial].

30. Plaintiff has exhausted all administrative remedies available under the Plan.

ERISA PROCEDURAL VIOLATIONS (IF APPLICABLE)

31. In processing Plaintiff's claim and appeal, Defendants violated ERISA's procedural requirements, including but not limited to:

☐ Failing to render a decision within the time limits prescribed by 29 C.F.R. § 2560.503-1
☐ Failing to provide adequate written notice of the reasons for denial
☐ Failing to provide the specific plan provisions on which the denial was based
☐ Failing to identify the medical or vocational experts whose advice was obtained
☐ Failing to provide a full and fair review of the claim
☐ Failing to consider all information submitted by Plaintiff
☐ Failing to provide new evidence or rationales prior to the final decision
☐ Failing to ensure independence and impartiality in the claims process
☐ Relying on biased or conflicted medical reviewers
☐ Other: [________________________________]

32. As a result of these procedural violations, Plaintiff is entitled to de novo review of the claim determination.

COUNT I: RECOVERY OF BENEFITS UNDER 29 U.S.C. § 1132(a)(1)(B)

33. Plaintiff incorporates by reference all preceding paragraphs.

34. Under 29 U.S.C. § 1132(a)(1)(B), a plan participant or beneficiary may bring a civil action "to recover benefits due to him under the terms of the plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan."

35. Plaintiff is entitled to [type of benefits] benefits under the terms of the Plan because [explain why plaintiff meets the Plan's definition of disability or other eligibility criteria].

36. Defendants wrongfully denied Plaintiff's claim for benefits based on [explain why the denial was improper].

37. Defendants' denial of benefits was arbitrary and capricious, an abuse of discretion, and/or not supported by substantial evidence in the administrative record.

38. Alternatively, under de novo review, Plaintiff is entitled to benefits because [explain basis for entitlement].

39. As a result of Defendants' wrongful denial of benefits, Plaintiff has been damaged in an amount to be proven at trial, but not less than $[________________], representing past-due benefits from [date] to present.

40. Plaintiff is also entitled to a declaration of rights to ongoing future benefits under the Plan.

COUNT II: EQUITABLE RELIEF UNDER 29 U.S.C. § 1132(a)(3) (ALTERNATIVE)

41. Plaintiff incorporates by reference all preceding paragraphs.

42. In the alternative, under 29 U.S.C. § 1132(a)(3), a plan participant, beneficiary, or fiduciary may bring a civil action "to obtain other appropriate equitable relief (i) to redress such violations or (ii) to enforce any provisions of this subchapter or the terms of the plan."

43. Defendants violated ERISA by [describe violations, e.g., breaching fiduciary duties, failing to comply with procedural requirements, acting in conflict of interest, etc.].

44. Plaintiff is entitled to appropriate equitable relief, including but not limited to:
    a. An injunction requiring Defendants to properly process Plaintiff's claim
    b. Reformation of the Plan to conform to ERISA requirements
    c. Surcharge for losses caused by Defendants' breach of fiduciary duty
    d. Equitable estoppel
    e. Other appropriate equitable relief

ATTORNEYS' FEES AND COSTS

45. Under 29 U.S.C. § 1132(g)(1), the Court may in its discretion award reasonable attorneys' fees and costs to either party in an action under ERISA.

46. Plaintiff is entitled to an award of reasonable attorneys' fees and costs incurred in prosecuting this action.

PRAYER FOR RELIEF

WHEREFORE, Plaintiff respectfully requests that this Court:

A. Enter judgment in favor of Plaintiff and against Defendants;

B. Award Plaintiff all [disability/health/life insurance] benefits due under the Plan, including past-due benefits from [date] to the present, plus pre-judgment interest;

C. Declare that Plaintiff is entitled to ongoing future benefits under the Plan;

D. Award Plaintiff appropriate equitable relief under 29 U.S.C. § 1132(a)(3);

E. Award Plaintiff reasonable attorneys' fees and costs pursuant to 29 U.S.C. § 1132(g);

F. Award Plaintiff pre-judgment and post-judgment interest at the highest legal rate;

G. Grant such other and further relief as the Court deems just and proper.

JURY DEMAND

☐ Plaintiff demands a trial by jury on all issues so triable.

[Note: Jury trials are generally not available for ERISA benefits claims under § 1132(a)(1)(B), but may be available for certain claims under § 1132(a)(3).]

Respectfully submitted,

Date: [__/__/____]

___________________________________
[Attorney Name]
[Bar Number]
[Firm Name]
[Address]
[City, State, ZIP]
[Telephone]
[Email]

Attorney for Plaintiff

VERIFICATION

I, [Plaintiff Name], declare under penalty of perjury under the laws of the United States that I have read the foregoing Complaint and that the facts stated therein are true and correct to the best of my knowledge.

Signature: ___________________________________

Printed Name: [________________________________]

Date: [__/__/____]

CHECKLIST FOR FILING

☐ Civil Cover Sheet (Form JS-44)
☐ Filing Fee or Application to Proceed In Forma Pauperis
☐ Summons for each Defendant
☐ Certificate of Service (upon service)
☐ Disclosure of Corporate Affiliations (if applicable)
☐ Notice of Consent to Magistrate Judge (if applicable)

SOURCES AND REFERENCES

• 29 U.S.C. § 1132 - Civil Enforcement
• 29 U.S.C. § 1133 - Claims Procedure
• 28 U.S.C. § 1331 - Federal Question Jurisdiction
• Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989)
• Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105 (2008)
• Hardt v. Reliance Standard Life Insurance Co., 560 U.S. 242 (2010)

This template is provided for educational and informational purposes. This Complaint must be reviewed and customized by a licensed attorney before filing.