The claim file referred to as the administrative file is the entire claim file that can be presented in court. Nothing can be added to the file once it is presented to the judge. In addition, you will want to have all the documents from the insurance company that outlines eligibility requirements and information regarding payment of benefits.
Whom to Get Information From
You must be mindful of who you are requesting documents from for the administrative file. The Plan Administrator is the correct person to request plan documentation. The Plan Administrator is not the same as the claims administrator. The Plan Administrator is usually the employer who sponsors the plan and the claims administrator works directly for the insurance company.
This request should be in writing, with the signed consent of the beneficiary. Documents requested should be the latest plan summary, latest annual report, complete plan description, any terminal, bargaining, or trust agreements, or any other contract that is used to establish or operate the plan. If you need help locating the Plan Administrator, you can use this website to locate them.
It’s also important to know that the Plan Administrator does not handle your entire case file. That would be left with the insurance claims adjustor.
Here is an example letter that you or your attorney can send to the Plan Administrator:
Pursuant to Section 503 of ERISA, 29 U.S.C. § 1133, and applicable Department of Labor regulations, including 29 C.F.R. § 2560.503-1(h)(2)(iii), Mr./Mrs. _________ requests all documents relevant to his/her claim for benefits that are in your office’s possession or control. Under 29 C.F.R. § 2560.503-1(m)(8), a document, record, or other information is “relevant to a claim for benefits” if it:
(i) Was relied upon in making the benefit determination;
(ii) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;
(iii) Demonstrates compliance with the administrative processes and safeguards required pursuant to paragraph (b)(5) of this section in making the benefit determination; or
(iv) In the case of a plan providing disability benefits, constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.
This will provide you with the information you need to start your claim. Plan sponsors are required by law to comply with ERISA laws and procedures. They are required by law to provide the entire plan for you, not just the summary, which is what is the typical document you will get from an HR department.
By law, the plan sponsor must provide you with the documents you have requested within 30 days from the date of the request. The law also states they must be mailed to the last known address so be sure to check what address you have on file.
If the plan administrator fails to provide these documents to you within 30 days, they can be fined up to $110 per day, which will be part of the award to you and your attorney. That is why it’s very important to request the documents from the proper entity. A judge will not issue a judgment against the claims adjuster for not providing the plan since it was the plan administrator’s responsibility.
Hiring a Disability Attorney
When you decide that it’s time to hire an attorney, the attorney will first make sure your claim qualifies under ERISA. Then the attorney will likely ask you questions to determine where in the process you are for your claim. For example:
- Has your claim been denied? If so, how many times?
- Have you exhausted your appeals?
- Have you submitted a claim at all yet?
This information gives the attorney a good starting point to work on your case as each situation will have a different set of obstacles. If you have not filed an appeal, but the deadline is approaching, your attorney can help you request an extension. If your claim is pending a decision, you may consider withdrawing your claim (if you have appeal time remaining) so that your attorney has time to review and add information to your administrative file.
Disability claims denials typically fall into one of the following categories:
- Sufficiency of Medical Evidence – for example, the insurance company may argue that the medical evidence does not support the existence of a medical diagnosis or is not severe enough to result in impairment.
- Specific Exclusions – some medical conditions are specifically excluded from coverage under a Short Term and/or Long Term disability insurance policy. There may also be exclusions for pre-existing conditions.
- Coverage Issues – these are more technical denials. For example, the insurance company may argue that the claimant did not work a minimum number of hours per week to qualify for benefits, or the insurance company may argue that there was no coverage because the claimant was terminated from employment and thus no longer had disability insurance coverage.
These areas will be heavily researched by your attorney to provide as much medical and legal support for your case as possible.
Information that you can provide to assist your attorney includes: medical records that show your current symptoms, results from physical exam and observations from therapy and surgeries, diagnostic test results, treatment plans, any prescribed medications you are taking, and your response to the medications.
Beware of Surveillance
Surveillance is used to document you doing things you are not supposed to. Anything can be taken out of context. Be sure to use your assistive devices at all times, do not push yourself to do more than you should, and stay off of social media. Read more about the trap of surveillance here.
The experienced disability attorneys at the Ortiz Law Firm can help you through the disability insurance appeals process. They only get paid if you win. You can seek help without worrying about upfront fees or costs. Our disability law experts will focus on your case so you can focus on your illness.
The Ortiz Law Firm has successfully represented people in disability cases across the United States. To see how we can help you win your long-term disability case, call us at (888) 321- 8131.