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April 2008 Archives

A disability insurance carrier's use of the same case manager to deny each internal appeal violates the claimant's right to a full and fair review.

The arbitrary and capricious standard that is used by courts to review some cases under the Employee Retirement Income Security Act of 1974 (ERISA), a decision by the administrator may be reversed based on a procedural error. In Rudzinski v. Metropolitan Life Ins. Co. , Slip Copy, 2007 WL 2746630 (N.D.Ill.2007), the court held that, "[i]n assuring a full and fair review for plan participants, ERISA regulations require that no deference be given to the initial decision, that the review be conducted by someone other than the initial reviewer, that someone trained and experienced in the appropriate field of medicine be consulted, and that a different consultant be involved in advising on the review."

LTD carrier's failure to produce the entire administrative record may result in a ruling favorable to the claimant.

The Employee Retirement Income Security Act of 1974 (ERISA) provides that the claims procedures of a disability benefits plan is reasonable only if, "a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits." A document, record, or other information shall be considered "relevant" to a claimant's claim if such document, record, or other information was relied upon in making the benefit determination; was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by ERISA in making the benefit determination. The persistent core requirements of review intended to be full and fair include knowing what evidence the decision-maker relied upon, having an opportunity to address the accuracy and reliability of that evidence, and having the decision-maker consider the evidence presented by both parties prior to reaching and rendering his decision. A LTD benefits claimant simply cannot know what evidence the decision-maker relied upon, nor have an opportunity to address the accuracy and reliability of that evidence, if it is withheld from the claimant.

Alan C. Olson & Associates | 2880 S Moorland Rd | New Berlin, WI 53151
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