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ERISA Compliance Requires Full And Fair Review

You’ve filed for long term disability benefits under the terms of your disability policy. You submitted what you believed to be proof that you cannot work and you were denied. What now? ERISA compliance requires the insurance company must give a “full and fair review” of your disability claim when reviewing an appeal. But what is a full and fair review? Under the Employee Retirement Income Security Act (“ERISA”), which governs employer issued disability insurance policies, you have the right to an administrative appeal with your insurance company.

A full and fair review means that:

  1. you are given a chance to submit your comments and records relating to your disability;
  2. you are given a complete copy of all documents, records, and other information relevant to your disability claim upon request and free of charge;
  3. your disability appeal is reviewed by taking into account everything you and your doctors submit;
  4. your disability appeal is reviewed by someone who was not involved in the initial review and denial;
  5. your disability insurance company consults with a “health care professional who has appropriate training and expertise” with your medical conditions.

Firstly, under ERISA you are entitled to know exactly what “evidence the insurance company relied upon when making their decision.” The insurance company will send you a “denial letter,” which should detail how the decision was made. This letter should contain the reason(s) for denial, a reference to the relevant provisions of the disability policy, and an outline with a timeline of your options to challenge the denial. When appropriate, the letter should also include the additional information or documentation needed to prove your disability and an explanation of why that information is necessary.

You are entitled to know how the insurance company came to its decision, including all relevant information it relied upon. This includes, for example, all written reports and medical records the insurance company used to evaluate your claim for total disability. Failure to inform you of such information would be a violation of the full and fair review requirement under ERISA.

Secondly, you must be given the opportunity to appeal a denial. If this was the first time your claim was denied, then the disability insurance company is required to give you a minimum of 180 days to appeal the denial. You must appeal in writing. When you appeal, you have the opportunity to submit more documents and information supporting your disability claim, such as letters from your doctors or other proof of your disability. Most importantly, the insurance company cannot deny your appeal based on a new reason without first notifying you and giving you an opportunity to respond.

For more information relating to this topic, see A New Reason for Denial Cannot be Given in a Final Decision on Appeal.

Lastly, the insurance company must review all of the documentation, evidence, and proof provided with the appeal in order to provide a full and fair review. The insurance company cannot just rely on the information from the initial claim without evaluating any new information provided. The insurance company must consider all the evidence available when reviewing an appeal and making a final decision on your appeal.

The full and fair review requirement under ERISA is complex, but a very important stage of your disability claim. If you were denied a full and fair review of your long term disability appeal, contact the attorneys at Dabdoub Law Firm to see how we can help.