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.”

A failure of the long-term disability benefits carrier to present evidence of the reviewing agent’s medical credentials also could result in a ruling in the claimant’s favor. The Rudzinski court cited, “fail[ure] to have medical personnel review Plaintiff’s first or second submissions” as another example of procedural irregularity contrary to ERISA’s requirements. Id. citing Martin v. Metropolitan Life Ins. Co. , 2002 WL 32072618, at*7 (E.D.Va. Sept. 23, 2002) (noting that plans must, have a physician or nurse consultant review a claimant’s application for benefits).

Alan Olson writes this web-log to provide helpful information regarding long-term disability cases. He practices long-term disability law throughout the United States from his offices in New Berlin, Wisconsin. Attorney Olson may be contacted at [email protected] with questions about the information posted here or for advice on specific disability benefit claims.


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