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Are you navigating the complexities of ERISA long-term disability claims and seeking to ensure a full and fair review of your case? This article will delve into your right to a full and fair review under ERISA regulations to equip you with essential knowledge for a successful claim.
What Is a Full and Fair Review Under ERISA?
ERISA, the Employee Retirement Income Security Act, provides guidelines and protections for individuals participating in employer-sponsored benefit plans. A crucial aspect of ERISA is the requirement for a full and fair review process for claimants whose benefits have been denied.
The legal framework of ERISA, specifically outlined in 29 USC Sec. 1133, explicitly guarantees claimants the right to a full and fair review of denied claims. This statutory provision is a protective measure, empowering individuals to seek a comprehensive evaluation of their benefit entitlements. Specifically, it states:
“In accordance with regulations of the Secretary, every employee benefit plan shall—
(Pub. L. 93–406, title I, § 503, Sept. 2, 1974, 88 Stat. 893.)
- Provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and
- Afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.”
In 2016, the Department of Labor (DOL) began a review of its procedures with the help of insurance plans, employers, advocacy groups, and disabled workers. After a thorough review, they developed 29 CFR §2560.503-1, a new rule that aims to make the claims review process more accurate and fair. It took effect on April 1, 2018, and now it covers most pending ERISA claims.
RELATED POST: Is Your Long-Term Disability Claim Governed By ERISA? Key Signs To Look For
Critical Components of a Full & Fair Review Under ERISA
- Clear Communication: Ensure all communication regarding the benefit determination process and deadlines are easy for the participant and beneficiaries to understand.
- Access to Information: Claimants are entitled to access all information and documentation relevant to the claimant’s claim for benefits. This includes the right to review any reports, medical records, or other evidence considered.
- Reasons for Denial: If a claim is denied, the plan administrator must provide specific reasons for the denial, reference the relevant plan provisions, and include an explanation for disagreeing with the findings of the claimant’s treating physicians, medical or vocational experts obtained by the insurer, or a disability determination made by the Social Security Administration.
- Claimant Participation: Claimants have the right to present additional evidence, provide testimony, respond to new evidence, and actively participate in the review process, ensuring that their perspectives and supporting information are considered.
- Impartiality: Insurance companies and their decision-makers must maintain impartiality during the review. This ensures that expert opinions and assessments are unbiased and free from potential conflicts of interest.
- Timely Review: ERISA mandates that the review process be conducted promptly, allowing claimants to challenge benefit denials without delay.
- Thorough Examination of Evidence: One of the fundamental requirements for a full and fair review is the thorough examination of all evidence related to the claim. This entails conducting a comprehensive assessment of the entire body of evidence, including medical records, expert opinions, and other relevant documentation.
This comprehensive framework of essential components forms the basis of a full and fair review process under ERISA, ensuring claimants can contest denials and receive a fair assessment of their benefit claims.
Recent Developments and Case Law
The significance of the full and fair review requirement is further underscored by judicial interpretations and precedents, emphasizing the need for insurers to adhere to the principles of fairness, transparency, and due process when evaluating and adjudicating benefit claims under ERISA.
Jette v. United of Omaha Life Ins. Co.
In Jette v. United of Omaha Life Ins. Co., the plaintiff argued that she did not receive a full and fair review of her long-term disability claim as required by ERISA. Specifically, she contended that United of Omaha failed to provide her with a copy of Dr. Thomson’s independent medical examination (IME) Report before upholding the termination of her LTD benefits. Jette believed that this failure warranted a remand of her case.
The United States District Court for the District of Massachusetts noted that under ERISA’s full and fair review requirement, an insurer is not obligated to disclose IME reports before making their decisions unless the insurer relies on the unshared IME report to find a new reason to deny coverage. However, the First Circuit Court of Appeals vacated the summary judgment granted by the district court, finding that the defendant committed a procedural violation, and this violation prejudiced Jette.
Zall v. Standard Ins. Co.
In Zall v. Standard Ins. Co., the United States District Court for the Western District of Wisconsin initially granted summary judgment to Standard Insurance Company, meaning they decided to favor the insurance company without a full trial. However, the Seventh Circuit Court of Appeals reversed this decision in January 2023. They found that Standard Insurance violated Zall’s right to a full and fair review by not providing him with a copy of a report prepared by Dr. Michelle Alpert, a consulting physician. This contravened the new claims-procedure regulations by the Department of Labor.
What To Do If You Were Denied a Full and Fair Review
Dealing with unfair treatment from your ERISA long-term disability insurer can be frustrating and challenging. However, there are specific steps you can take to address this situation and ensure you receive the fair treatment and benefits you deserve.
Review Your Policy and Correspondence Carefully
Start by reviewing your insurance policy and any correspondence you have received from your insurer. Pay close attention to the reasons for the denial or unfair treatment. Understanding the specifics of your policy and the insurer’s actions will help you determine the appropriate course of action.
Seek Legal Counsel
If you believe your insurer has wrongly denied your claim, consider seeking legal advice from an attorney experienced in ERISA and long-term disability claims. An attorney can provide valuable guidance on your rights and options and represent your interests in dealings with the insurer.
File an Appeal
If your insurer denied your long-term disability claim unfairly, you have the right to file an appeal. Work closely with your legal counsel to prepare a strong appeal, including compelling evidence and documentation to support your case.
FREE RESOURCE: Appeal a Long-Term Disability Denial with our LTD Appeal Guide
Consider Litigation
Pursuing litigation may sometimes be necessary to resolve the dispute. Your attorney can advise you on the appropriate course of action based on the specifics of your situation and the insurer’s response to your appeal.
Remember, navigating the complexities of ERISA and long-term disability claims can be challenging, but with the right approach and support, you can work towards securing the benefits you rightfully deserve.
Schedule a Free Case Review with Ortiz Law Firm
Navigating the ever-changing landscape of ERISA law can be a real challenge. The rules for full and fair review are just the beginning. Federal laws have many complexities and loopholes that give insurance companies ways to avoid their responsibilities and unfairly delay or deny disability benefits.
If you’re struggling with a group disability claim and want to secure your benefits as quickly as possible, it’s crucial to enlist the help of an experienced ERISA disability attorney. If your initial claim has already been denied, time is of the essence.
Contact Ortiz Law Firm today to set up a free case review. We can prepare a comprehensive appeal package and ensure it is submitted promptly and before the expiration of your appeal deadline. Call (888) 321-8131 to get help with your claim.