You Need To Get The Goods Before You Get The Benefits

Before you can launch a successful appeal against your long-term disability benefits carrier, you have to “get the goods.” What I’m referring to are the pieces of information that your carrier has been using against you behind the scenes.

The U.S. Department of Labor (“DOL”) has certain regulations governing the submission and determination of claims under employee welfare benefits plans. These regulations specify that a claims administrator is required to have certain procedures to comply with the requirement that it has established a “reasonable claims procedure”. A reasonable claims procedure is defined in DOL Regulations as procedures to “ensure and verify that benefit claim determinations are made in accordance with governing plan documents and that plan provisions have been applied consistently with respect to similarly situated claimants.”

The Regulations further contemplate that a claimant is to have access to these claims procedures. Under a related Regulation [29 C.F.R. Section 2560-503-1(j)], a claimant is entitled to reasonable access to all “relevant documents.” “Relevant documents” are defined as those maintained by the claims fiduciary. Thus, under the regulatory scheme, a claimant is entitled to disclosure of all “relevant documents,” including those that ensure that the terms of the plan are applied consistently.

Moreover, the DOL’s intent in enacting these Regulations, removes any doubt concerning the public assess to a claims administrator’s claim procedures. In adopting these Regulations, the DOL stated that the “claimant should receive any information demonstrating that, in making the adverse benefit determination, the plan complied with its own processes for ensuring appropriate decision-making and consistency .” This allows the claimant copies of any “internal rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination.” This includes copies of all Benefit Claims Manuals and internal claim review guidelines.

Based on the foregoing, it is absolutely essential that your attorney ask your carrier to provide copies of all claims manuals, claims guidelines, training guidelines, and/or any other documents which demonstrate the carrier’s compliance with 29 C.F.R. Section 2560.503-1(b)(5).

In addition, you or your attorney should ask your long-term disability benefits carrier to provide proof that the applicable insurance policy was submitted to and was approved by the state insurance commissioner and U.S. Department of Labor.

Lastly, require your carrier to identify the Plan Administrator and its address; or, provide documents that will identify the Plan Administrator for the purpose of serving suit or the filing of a lawsuit under state statutes.

Only after you and your attorney have received the above requested materials, will you be in a proper position to submit additional documents for the carrier to consider, as well as written comments necessary to win your claim for long-term disability benefits.

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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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