What Are Adverse Benefits Determination Letters?

Have you received an Adverse Benefits Determination letter from your disability insurance company? If you have, you’re probably wondering if the insurance company can stop paying long-term disability benefits while they review a change in the definition of disability. You should continue to receive long-term disability benefits while the insurance company reviews a change in the definition of disability.

Your insurance policy may have a change in the definition of disability. If it does, the insurance company will conduct a review. The policy may require that initially you be disabled from your own occupation. But the definition can change after a period of time. It may then require you be disabled from any occupation.

If this is the case, the insurance company will conduct a review. In the review they will decide if you meet the criteria for the change. It is possible a person is disabled from working in their own occupation. However, they may not be disabled from working in another occupation. The other occupation is based on their training, experience, and education.

The insurance company may stop paying your benefits during the review. However, under ERISA law, they must send you what is known as an “adverse benefits determination” notification. This letter serves as a formal notice that there is a change in your disability benefits (denial, reduction, termination). It also gives you a chance to submit an appeal to your insurance company.

If the insurance company ends your disability benefits while reviewing your disability claims and does not send you an adverse benefits determination letter, they are in violation of ERISA law. Lately, many insurance companies, such as Reliance Standard and Sun Life, have decided to stop paying disability benefits while they review a claim.

Our law firm has been successful in getting the insurance companies to resume payment of disability benefits whenever this occurs.


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