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What Is a “Full & Fair Review” Under ERISA?

The Employee Retirement Income Security Act of 1974 (ERISA) is a body of federal legislation that governs a wide range of employer-sponsored benefits for workers. This includes long-term disability insurance coverage you get as a perk of employment.

There is a distinct appeals procedure when it comes to employer-provided long-term disability insurance plans (also known as ERISA policies). One of the rules here is that your insurance company must provide a “full and fair review” of your claim and appeal before you can file suit against the insurance company in federal court. So, what does a full and fair review of an ERISA disability claim look like in practice?

What Constitutes a “Full and Fair Review” of an ERISA Disability Claim/Appeal?

The rules regarding ERISA claims procedures are to be found in §503 of the Act; it is from here that the words “full and fair review” originate. The Department of Labor updated this area of the legislation in 2018, and the new provision (which affects claims initially filed after April 1, 2018) offers more detailed guidance on what the phrase means in real terms. The following are all relevant factors to consider.

The Handling of New Evidence

If your insurer wishes to rely on new evidence to reject your disability insurance claim or terminate your previously established entitlement to monthly benefits, it must first give you a fair chance to respond to this evidence. This new material often takes the form of a report from a medical or vocational expert, such as an independent medical examination (IME).

If your insurance company sends you for an independent medical examination, it may select a physician with whom it has an ongoing relationship. While the doctor may not be in the employ of your insurer or receiving payments directly from the company, they may benefit from repeat business coming from IMEs. This dynamic can incentivize physicians to find in favor of insurers rather than claimants, which is why the results of IMEs often differ from the findings of claimants’ treating physicians. Your Ohio ERISA disability attorney will be able to tell you whether your insurer has violated any rules in this regard.

The Impartiality of Decision-Makers

Insurance company experts who make judgments on your claim must also be impartial in order for a full and fair review to have taken place. This means the company should not incentivize them as employees with bonuses for denials or offer them increased remuneration based on their decisions to deny.

Complete Explanation of the Reason for a Denial

ERISA disability insurers often attempt to wrongfully deny claims using vague justifications. However, under the updated terms of §503, doing so is a violation of the requirement to provide a full and fair review of claims. If, in refusing to pay out on your claim, your insurer disagrees with the reports of independent vocational or healthcare professionals, or with the findings of the Social Security Administration regarding your disability status, the company must properly justify their position.

Limitation Periods & Deadlines

One of the most pressing issues when it comes to ERISA disability insurance claim appeals is often that of deadlines. After you receive a denial on your initial claim, you usually have six months within which to submit your mandatory administrative appeal; failure to do so within this timeframe can be fatal.

In order to ensure you know exactly when you need to submit all the relevant documentation, the rules require any letter from your insurer regarding claim or appeal denials to indicate the calendar date by which you must submit an appeal or file a lawsuit.

Remember, the deadline date may not be in a prominent position on the correspondence you receive, as it benefits your insurer if you forget about it. There will always be a deadline, so be sure to find it and keep it in your records as soon as you receive a letter about a denied claim or appeal. If you’re unsure, your long-term disability attorney will be able to guide you.

What To Do If Your ERISA Long-Term Disability Insurer Has Treated You Unfairly

As you can see, the law around ERISA is complex and constantly evolving. The “full and fair review” rules are just the tip of the iceberg; there are countless intricacies and loopholes in the federal legislation that allow insurers to escape their obligations and wrongfully delay or deny monthly disability insurance benefits.

If you’re having trouble with a group disability claim (whether it’s because you didn’t receive a full and fair review or for another reason) and you want to ensure that you secure your benefit entitlements as quickly as possible, you need to hire a seasoned and successful ERISA disability lawyer. Contact DarrasLaw today to schedule a free initial policy analysis, free claim assistance, or free analysis of your appeal. If you’ve already received an initial claim denial from your insurer, it’s crucial that you start the process of filing a timely, comprehensive administrative appeal as soon as possible. Don’t wait.

DarrasLaw is Americas' most honored and decorated disability litigation firm in the country. Mr. Darras has seen more, evaluated more, litigated more, and resolved more individual and group long term disability and long-term care cases than any other lawyer in the United States.

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