Keep in mind that ERISA Stands for Employee Retirement Income Security Act. It’s a federal act that governs all employee benefits so if your employer has a long-term disability insurance plan and you get long-term disability insurance or you’re denied long-term disability insurance, then this federal act governs your plan. Part of that act is that you are entitled to get a copy of the entire claim file. This is something that we routinely do in every single case that comes through our doors. Why do we do it? Because you find valuable information in the insurance company’s files.
For example, I just filed a long-term disability appeal today and one of the things that I found when I requested the claim file was that my client never knew in the first appeal that there was an independent claim reviewer, a medical nurse practitioner who was not a doctor, who essentially wrote the denial letter.
You got that right, they essentially wrote the denial letter. In other words, what the claims reviewer did was they took the nurse practitioner’s content from their medical report, they copy and paste it into the denial letter and they changed little things. Like for an employee, you’ll often see the two letters, capital EE for employee. Or sometimes you’ll see a date like August 19th, 2019, it’ll be 8/19/19. What they’ll do is they’ll change stupid stuff like they’ll put a 08/19/2019 instead of just leaving it to be a straight 19. And they’ll take employees and they’ll say, “You,” or “You were,” or “You are.” They’ll change from present tense to past tense, they’ll change it around to make it sound prettier and make it sound like they drafted it but they really didn’t draft it.
I was shocked when I was preparing this appeal because we got this claim file and in what we found was that after two appeals, two times, this happened with two different claims reviewers, all they did was take a nurse practitioner and one took a nurse disability consultant. Again, who’s employed by the insurance company that is deciding whether or not to give you benefits, they took that nurse disability consultant’s report and they literally copied and pasted it with a few minor changes here and there and that became their decision.
Always Keep This Major Aspect in Mind
Now remember, every time the insurance company is reviewing your claim for whether to grant or deny your benefits, they have a fiduciary duty to act in your favor. They have a fiduciary duty to review all of the evidence, they have a fiduciary duty to make sure that everything that they do is to benefit you. Now, that doesn’t mean that they have to grant your benefits but it does mean that they have to have an eye towards your best interests. So one of the things that they need to do is they need to tell you who was reviewing their claim file, who is writing this analysis. They have a duty to provide you a full and a fair review of your long-term disability claim and if they don’t do that, then they have violated ERISA, the Employer Retirement Income Security Act, and that’s where I come in.
When people are denied their long-term disability benefits, a lot of times you can request a claim file, -it’s like 2000 pages of documents- and some people are just so overwhelmed by the content that is thrown their way and they just don’t know what to do. They don’t know how to read the long-term disability policy to learn what are the rules, what are the guidelines, what am I trying to do here? So we’re trained on how to do that.
We have done a bunch of them and we know what to look for when we’re reviewing these cases. When we get that claim file in, we know exactly what to look for. You want to look, I’ll give you a hint right here and now. You don’t have to pay for this, this is all free information, I’m just giving it to you out of the goodness of my heart because I think that you need it. When you’re looking through the claim file, you need to look at the chronological activity list, or sometimes they call it a chronological activity report. That essentially is a detailed list of everything that a claims specialist does during every part of that claim. So for example, in this case that I just reviewed, they said that there was no physician certifying complete disability. Well, hold on, because you said that on February 7th, but on January 20th, I have a copy of a continuing disability form filled out by my client’s physician, her treating physician, who was a specialist by the way, and it says that I have not released my patient to go back to work.
I hope this has been helpful. If you have any questions about how to request a claim file or what to look for when you get the claim file, send me an email. I’d be happy to chat with you about it. Thanks.