While ERISA always has required denial notices for long-term disability benefits claims to contain certain elements, the Department of Labor (DOL) recently revised some of those requirements, which apply to all claims filed by claimants seeking LTD benefits after April 1, 2018. These requirements apply to all denial notices, whether they are initial or final denial notices.
First, all denial notices must contain a specific reason for the denial. The notice must refer explicitly to the specific plan provisions on which the denial is based. Additionally, initial denial notices must specifically describe any further information needed from the individuals that is necessary to complete their claims.
Denial notices also must contain a discussion of the decision, which explains the reasons that the claims administrator either does agree or doesn’t agree with the opinions of any medical or vocational professionals who treated or evaluated the claimants or whom the plan enlisted to evaluate the claimants, as well as any disability determination by the Social Security Administration.
Furthermore, if the denial relies on an exclusion or limitation in the plan benefits, the denial must contain an explanation for the scientific or clinical judgment leading to the application of the exclusion at issue. If the notice does not contain this explanation, then it must contain a statement that notifies claimants that they can receive the explanation in writing upon request.
The denial notices also must contain reference to any internal rules or guidelines that the claims administrators relied on in making their decision to deny the claim for benefits. A complete explanation of all appeals procedures all be a part of the denial notices.
Finally, the denial notices must advise claimants of the following rights:
· The right to access on request copies of all relevant documents and records free of charge
· The right to appeal the denial of benefits under the plan’s appeal procedures, including the applicable time limits
· The right of the individuals to sue under ERISA following a final denial, as well as applicable time limits and the date on which the right to file a lawsuit regarding the denial expires.
It can benefit you greatly to get legal advice about all the potential means of building and maintaining the most effective ERISA long-term disability claim possible and guidance as to the pitfalls to avoid. Bonnici Law Group provides skilled, aggressive legal representation on a regular basis for individuals who are seeking long-term disability benefits under insurance policies governed by ERISA. Our priority is to represent your interests and protect your rights to the benefits that you deserve. Call us at 619-259-5199 and schedule an appointment to meet with us about your case today.