Part 1 – What to Do if Your Claim is Denied
If you have ever tried to make a claim under a private disability benefits plan, you have likely heard of the “arbitrary and capricious” standard. Courts use this standard to evaluate whether an administrator of a private disability benefits plan has properly decided a claim for disability benefits. If you become disabled and file a claim for private disability benefits, a common course of events is this: you and your doctor complete an application and provide medical records establishing that you have one or more illnesses or injuries that limit your ability to work. You may assume that because you have paid for disability insurance, you are entitled to benefits once you have received a diagnosis.
However, providing evidence of an illness or injury and a statement from the doctor that you are unable to work, may not be enough to obtain benefits. For most private disability insurance plans governed by the Employment Retirement Income Security Act of 1974 (known as “ERISA”), an insurance plan administrator is only obligated to consider evidence that you or your doctor send in. The Plan Administrator is not required to go beyond that evidence, or even, to make the best or most fair decision for the participant. Instead, if a disability benefits plan administrator reserves discretion to decide benefits to the plan administrator (and most do), the plan administrator is only required to review and consider the evidence presented in a reasonable, non-arbitrary manner, and is free to reject the claim if in the plan administrator’s judgment, the participant did not produce sufficient objective medical evidence of how the diagnosed condition limits that person’s ability to work.
A disabled individual and his or her busy primary care doctor are typically ill-equipped to establish the vocational impact of an individual’s disability. A disability benefits claim may be denied just because the participant is unable to provide evidence to show how the condition limits his ability to work. There is, however, hope on appeal, because of ERISA’s appeal procedures.
If your private disability benefit claim is denied, you must appeal the denial to the plan administrator, following the rules set forth in the plan and within the plan’s established deadline. Your appeal must include medical evidence of how your condition limits or prohibits you from working. If you don’t appeal or don’t follow the plan’s procedures, you may lose your right to later bring a case in court.
Subsequent posts will include steps for appeal and details of how to obtain the evidence you need.
Please contact Patricia Bellac at PSB Law Firm, LLC, (303) 622-3883 for your private disability insurance plan claims and appeals.