An Oregon court recently found UNUM violated ERISA’s full and fair review requirement when it denied a claim for a new reason. ERISA’s full and fair review requirement is meant to afford claimants an opportunity to have their claim reviewed with all available information and respond to any reason for a denial. In some instances, the insurance company will issue a denial or termination on appeal that is based on a new or different reason from the initial denial. This is a violation of the full and fair review.
Alison Gary, from Oregon, filed for disability benefits after she could no longer work in her occupation as an attorney. Her insurance policy was part of her employee benefits and thus governed by ERISA. As part of the claims procedure, ERISA requires that a plan afford the participant a full and fair review of their claim. Part of the full and fair review requirement is that a claimant is given an opportunity to respond to the denial. In some instances the insurance company will cite a reason for an appeal denial that is new or different from the original reason for denial.
In Gary v. UNUM, that is exactly what happen. Ms. Gary appealed UNUM’s termination of her benefits, and in the appeal denial they cited an additional reason for denying her benefits. However, that denial did not give her the right to another internal review. Ms. Gary was never given a chance to respond to the additional basis for the denial. UNUM’s failure to provide the another review violated ERISA’s full and fair review requirement.
The Oregon Court analyzed the full and fair review requirement and found that the claimant is essentially denied due process at the administrative level. This is really important because the next option is to file a lawsuit. However, the court, generally, will be limited to the information that is in the claim file at the time of the denial. Since Ms. Gary was not given a chance to respond to the additional reason UNUM based its denial on, the claim file is lacking pertinent evidence of her disability.
This case presents a problem we see often in ERISA cases. Insurance companies sometimes fail to follow ERISA regulations and requirements and the claimant is the one who suffers. Each person fighting against a wrongful denial or termination should be given an opportunity to present their medical and non-medical evidence in support of their disability. They should also be given an opportunity to refute the reasons for the denial, initially and on appeal.
If you or someone you know has not been provided with a full and fair review of their disability claim, call our experienced disability insurance lawyers today for a free case evaluation. We have extensive experience dealing with these types of ERISA violations. The Dabdoub Law Firm can help get you the benefits you deserve.