What is the “full and fair review” that an ERISA plan administrator must provide me in the case of a denial of LTD benefits?

What is the “full and fair review” that an ERISA plan administrator must provide me in the case of a denial of LTD benefits?

The Employee Retirement Income Security Act (ERISA) governs the administration of most long-term disability insurance plans. Under ERISA, if plan administrators deny a participant’s claim for long-term disability (LTD), the plan is entitled to a “full and fair review” of the denial of benefits. Over the years, various courts have interpreted the meaning of a full and fair review concerning the denial of LTD benefits as outlined in ERISA. For example, courts historically have held that a full and fair review requires at least three core elements:

• Knowledge of what the decisionmaker relied on
• Opportunity to address the accuracy and reliability of that evidence
• Consideration of evidence presented by both parties before a decision is made

Furthermore, in 2018, the U.S. Department of Labor revised ERISA claims regulations concerning a full and fair review. These changes give claimants in ERISA-governed benefits plan specific rights, such as:

• Access to the relevant evidence and standards used by decisionmakers
• Ensuring the impartiality of decisionmakers
• Giving claimants notice and a fair opportunity to respond to the evidence, rationales, and guidelines for the decision
• Full and fair communications to the claimant of the bases for the plan’s decision

To further these requirements, denial notices issued by these plans must contain a more thorough explanation of the reasons for the denial, including any rationale for rejecting the contrary opinions of experts. This explanation also must specify which rules and regulations used by plan administrators in deciding to deny the claim. These notices also must contain statements notifying claimants of their right to a copy of their entire claim file, free of charge.

Additionally, if a plan denies a claim based on new or supplemental evidence or rationales, the plan first must give the claimant the chance to review and respond to the evidence or grounds. Denial notices also must contain specific calendar dates concerning contractual limitations, such as appeal deadlines.

Bonnici Law Group has handled the claims of countless individuals who have encountered difficulties in procuring long-term disability benefits under their employers’ ERISA-governed insurance policies. We will protect your rights and advocate on your behalf throughout every stage of the claims process. Call our office at 619-259-5199 to set up an appointment to speak with us today.

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