When an employee in Chicago receives a claim denial letter from his long term disability benefits insurer, the letter contains a great deal of very important information. The U.S. Department of Labor’s ERISA regulations (29 C.F.R. § 2560.503-1(g)) detail what the plan administrator (usually your disability insurance company) must state in a denial letter. The letter should identify the specific reasons for the denial, the specific plan provisions on which the determination is based, and any additional information you could provide to perfect your claim with an explanation for why such information is necessary, and a description of the plan’s review procedures and time limits—including your right to bring a civil action under ERISA § 502(a) following exhaustion of the administrative review process. While sometimes an incomplete letter only signifies a lack of explanation for the actual activity that occurred in reviewing your claim, often the absence of identification of information in the letter signals a break down in the administrator or insurer’s review, which may entitle you to the disability benefits. An ERISA Disability Attorney can assist you in analyzing the information in the letter and determining if the letter was written properly. An ERISA Disability Attorney can also help you seek the necessary missing information in preparation of your administrative appeal. Except for a few special circumstances, you are required to administratively appeal a denial at least once before you are able to file a lawsuit. If done properly, this administrative appeal can be cost saving and efficient for you to obtain your benefits much more quickly than you would be able to in court.
Though the administrator is required to put these various pieces of information in your denial letter, there is often a large body of information that you will never see, unless specifically and properly requested. The information that is not contained in the denial letter is often the most vital information you will need in order to overcome the denial of benefits. Everything that relates to your claim, or the administrator’s review of your claim, should appear in something called a “claims file.” The claims file should contain every document that you submitted to the administrator (original claim form, faxes, medical records, etc.) along with attending physicians’ statements, employment information, and various other documents the administrator obtained. Every claims file is unique, but there are certain relevant documents that will almost always exist if your claim was reviewed by a “peer reviewer” or an “independent medical examiner” (IME). If your denial letter states that the insurer relied on the medical determination of a peer reviewer or IME, you need to see all original reports generated by these reviewers. Peer reviewers and IME’s are paid by the insurance companies to review your medical files, or examine you and render a medical determination as to your medical condition(s) and your functional abilities. If the administrator totally relies on the medical opinions of these reviewers, it is imperative that you read and analyze their reports so that you can ensure that they have a firm grasp on your condition(s). It is often the case that these peer reviewers or IMEs are not properly considering all of the medical records or addressing all of your treating physicians’ opinions. If they fail to properly consider your medical evidence, your benefits could be wrongfully denied or tremendously delayed.
In a recent case out of the Sixth Circuit, the Court vacated a denial of benefits because the medical file report relied upon by Liberty Life Assurance Co. of Boston (“Liberty”) was arbitrary. Niswonger v. PNC Bank Corp. & Affiliates Long Term Disability Plan, No. 13-4282 (6th Cir., May 14, 2015). This was the second case that the plaintiff had brought in federal court under ERISA § 502(a). During the first case, the district court granted him judgment on the administrative record, finding that Liberty had disregarded overwhelming evidence that he was unable to perform his own occupation. The second case was a review for whether the plaintiff, a former financial advisor, was capable of “any occupation.” The Sixth Circuit found that again, Liberty ignored evidence. Liberty had relied on a file reviewer who completely ignored the specific conclusions of two board certified pulmonologists and multiple objective tests supporting the plaintiff’s disability from any occupation. The file reviewer had improperly found that the test results and analysis were inconclusive. The Sixth Circuit remanded the case to district court for a further remand to Liberty to re-examine the claims in light of the full record.
Before filing a case in court, you want to ensure that anyone who has reviewed your case has properly reviewed all of your relevant medical evidence and treating physicians’ opinions. While ERISA Disability Attorneys cannot prevent an insurer or administrator from ignoring evidence or mishandling your claim, they can help you thoroughly understand your denial and prepare a time efficient strategy for pursuing the benefits to which you are entitled.