Over the past 15 years, I have represented hundreds of claimants in their claims for disability benefits governed by the Employee Retirement Income Security Act of 1974, also known as ERISA. If an ERISA disability claim is denied, a claimant must appeal that denial to the plan administrator or insurance company before he or she is able to file a lawsuit. The appeals process is referred to as exhausting administrative remedies (though there is no administrative agency involved). The ERISA Regulations provide rules that an administrator must follow in order to give a claimant a “full and fair review.” See ERISA § 503; 29 CFR § 2560.503-1 (Claims procedure).
Effective April 1, 2018, the ERISA Regulations were changed to require that an insurance company or administrator provide to the claimant copies of new evidence it obtains after a claimant submits an appeal so that the claimant has an opportunity to respond to the new evidence before the insurance company issues a final claim decision. Some insurance companies, however, refuse to provide this evidence to claimants who filed their disability claims before April 1, 2018.
What if you fall into this pre-April 1, 2018 category? Do you have any rights to know what the insurance company is relying on before it issues a final decision on your appeal?