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New Department of Labor Regulations for ERISA Disability Claims

Over the past few months we have been seeing an increase in denial letters from various insurance companies that contain information not previously seen. This information includes a notice of claimant rights written in multiple languages, and in the case of final denials of benefits the notification to claimants of the exact date the Statute of Limitations to bring a lawsuit under ERISA to seek one’s benefits will expire. The inclusion of these items was an early rollout by various insurance companies in advance of the Department of Labor’s new disability claim regulations set to take effect on April 1, 2018.

From the perspective of a plaintiff’s attorney representing people trying to secure disability insurance benefits, there are two key regulation changes that we believe are most beneficial to the claimant/insured: the “Right to Review and Respond to New Information Before Final Decision” and “Deemed Exhaustion of Claims and Appeal Processes.” These changes are a direct result of the efforts by plaintiffs’ attorneys to convince Courts for the need of such changes.

First, and the most important as it relates to the administrative appeal process is the right of the insured while their claim is under an administrative appeal review by the insurance carrier to review any new evidence created by the insurance carrier during the appeal review process and respond to same. The Department of Labor states:

Right to Review and Respond to New Information Before Final Decision. The final rule prohibits plans from denying benefits on appeal based on new or additional evidence or rationales that were not included when the benefit was denied at the claims stage, unless the claimant is given notice and a fair opportunity to respond.

The “new evidence” addressed is assuredly meant to target at any medical reviews conducted at the request of the insurance company in response to the insured’s administrative appeal. Prior to this formal change in regulation an insurance company did not have to provide the insured with a copy of any new information and/or medical review reports created during the appeal review. This in turn prevented an insured from being able to respond to the opinion(s) of the insurance company’s doctor(s). Although some insurance companies have commonly provided medical review reports to an insured with a request that the insured’s doctors respond to same before a final decision is rendered, it is now a requirement. It appears that gone are the days when an insurance company can deny an administrative appeal without affording a claimant the right to respond to the very medical opinions that the company is relying on to deny their appeal.

The second regulation change that greatly expands the rights of the insured is a requirement by the insurance company to strictly adhere to claims procedures. Per the Department of Labor:

Deemed Exhaustion of Claims and Appeal Processes. If plans do not adhere to all claims processing rules, the claimant is deemed to have exhausted the administrative remedies available under the plan, unless the violation was the result of a minor error and other specified conditions are met. If the claimant is deemed to have exhausted the administrative remedies available under the plan, the claim or appeal is deemed denied on review without the exercise of discretion by a fiduciary and the claimant may immediately pursue his or her claim in court. The final rule also provides that the plan must treat a claim as re-filed on appeal upon the plan’s receipt of a court’s decision rejecting the claimant’s request for review.

This change is intended to overturn years of case law, which had determined that only “substantial compliance” with the regulations was required. This requirement to strictly adhere to claims procedures could open the door to claimants being able to terminate the claims process and file a lawsuit to determine if an error occurred and whether the error on the part of the insurance company was more than minor. According to the Department of Labor, if the error is deemed to be more than minor then the deference a Court may normally provide to the insurance carrier will no longer be in place and the insured’s claim would be entitled to a “de novo” review. In ERISA litigation a de novo review is the best standard of review an insured can obtain. However, it will remain to be seen how Courts address this regulation change as it conflicts with case law in many jurisdictions as well as case law set forth by the Supreme Court. Regardless, this regulation change will help guarantee that insurance companies will comply with claims procedures and hopefully end the seemingly endless delay tactics many companies employ when rendering a decision on a claim.

It remains to be seen if the Department of Labor’s regulation changes will make a noticeable impact to the benefits of insureds and claimants, but the fact that changes are being made is a step in the right direction to protect insured’s rights under ERISA governed disability insurance policies. For more information about the regulation changes, please feel free to review the Department of Labor’s fact sheet regarding same.

If you are currently on disability or thinking about filing a disability claim and wanted to know how these regulation changes affect you, please do not hesitate to reach out to speak to one of our disability insurance attorneys.

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Reviews from Our Clients

S.S.

I am a physician in my 30s who was practicing in my hospital based medical specialty until my Multiple Sclerosis diagnosis began to severely limit my physical ability to work.

My husband and I were obviously in distress at these very unwanted life changes and frankly overwhelmed with the possibility of a long and traumatizing legal battle ahead of us. We knew we were legally entitled to benefits through the separate private individual and employer based ERISA disability insurance policies we had, but even cursory research and discussion with colleagues made it clear that insurance companies will strategize with their own legal teams to find ways to not pay out benefits. We found many before us who had fallen unwittingly into legal pitfalls that prevented them from ultimately obtaining benefits. We realized we needed to seek legal counseling.

We found Dell Disability Firm through their youtube channel where their associates have videos discussing the legal intricacies and latest developments in private disability law. I was impressed by their dedication to the field and reached out through their website to request a free consultation.

We were delighted to hear that Mr. Steven Dell himself would be willing to take our case and felt assured that we would be represented by the best of the best.

We have not been disappointed in our expectation and have, in fact, been consistently very impressed. Steven Dell is clearly both knowledgeable and wise about dealing with these issues but more importantly, has shown kindness and impeccable honesty at each step of the way.

Merlin has demonstrated a very high capacity for organizing and handling the endless myriad of documents and communications between us and the insurance companies. She has also been very compassionate, accessible and forthcoming in dealing with our many anxiety fueled emails and telephone calls to her and we are very grateful for her involvement.

For over 7 months, we have been working closely with Steven Dell and Merlin Bryan from Dell Disability Lawyers as they have guided us through the process of review and initial application for benefits from our two insurance policies (Hartford and Ameritas).

We are happy to announce we just received approval of claim from the Hartford insurance company.

At this time we are still working with this firm as we await the final decisions from Ameritas policy that we are hopeful will have a similar outcome.

As anyone with a chronic and progressive illness can tell you, time becomes a very precious commodity. Through their representation, Dell Disability Associates has allowed us to focus the majority of our time enjoying the time and function I have left while resting assured that our disability case laid in competent and caring hands.

The truth is that no amount of money can make up for what we have lost, but it is a huge comfort to have a team like Dell Disability Lawyers at our sides to help us ensure we will be able to continue to care for ourselves and our families.

We highly recommend Dell Disability Lawyers, Mr. Steven Dell and Ms. Merlin Bryan to handle your disability insurance claim.

Thank you Steven, thank you Merlin!

We will certainly plan on leaving another review for completeness once we have our final decision from Ameritas.

Paula B.

I have been working with Dell Disability Lawyers for the past 5 years concerning my disability as it pertained to my employer. I have been more than pleased with them the entire time. They have always kept me informed of any paperwork needing completed or any changes coming ahead. Nothing has been a surprise. I would recommend them to you to help with your disability case if you’re trying to dip into the policy you’ve been paying for.

Michael M.

I am a physician who has been disabled for over 10 years. During this time I have been represented by Cesar Gavidia and his assistant Danielle Lauria. Their representation on my behalf has allowed me to concentrate on dealing with my disability/disease process and all associated complications and not having to deal with all the things that are necessary in a disability claim. Based on my personal experience from many years of practicing medicine I would consider their work product, insight and effort in the disability claim procedures to be superior. I would recommnend them, which I have done, with my highest level of confidence. In short, you well served with this practice.

Dan P.

I had to retire from my career due to a bad back that restricted me from performing my duties. I had LTD insurance and after a few years of receiving monthly benefits from this insurance company, they notified me that my benefits were terminated stating that I don’t qualify due to my duties not fitting into some “national job description” and a nurse had deemed me eligible to go back to work. Its a crushing feeling to have this told to you over the phone with hardly any information given. Luckily, I came across Dell Disability Lawyers and spoke with Attorney Palamara who calmed me down and stated they would take my case. Within a couple of months my benefits were restored, and I had piece of mind. I cannot thank Attorney Palamara and the staff enough at Dell Disability for their professionalism, no nonsense approach, personal and timely communication and quick ability to litigate my case.

Jen S.

I wanted to thank Mr. Symonds and his legal assistant Sonia for their professionalism, guidance and dedication towards my LTD claim. Going through the denial process on my own was going to get me sicker and knew it was time for help right away. I reached out to Dell Disability Lawyers for assistance and not too long after my call, I was connected with Sonia – Soon after that, I was talking about my case with Mr. Symonds. After a long and tedious process with the LTD insurer, we won the case. The wait can absolutely be lengthy, but in the end, it was all very much worth the fight. Thank you both so much for all that you have done for me! I also want to thank those who assisted in keeping me updated, as needed. Highly recommended for anyone who is going through the brutal process of an LTD denial.

Carl G.

I would like to thank Dell Disability Lawyers for taking care of my case and help me get the insurance coverage that I was rightfully in need of. Specially, I would like to thank Lawyer Alexander Palamara and RIGHT-HAND legal assistant, Sonia Nogueira, who made this process less stressful. They answered all my questions and kept me informed every step of the way.

Don’t get me wrong. They never promised or told me that I was going to win my case, as no one can guarantee that for you. What they did do, was letting me know that they were working hard for me and to keep positive. Something that I recommend everyone to do is to subscribe to their YouTube channel. That will give you an idea on how they operate and why they (for most of their cases) win their cases.

Since I was awarded disability, I am still having surgeries and thanks to Dell Lawyers, I’ve been able to cover all those expenses.

Warm regards to everyone at Dell.

Clarisa B.

I’m so very Grateful and Thankful for the team at Dell. They worked tirelessly to get the best outcome for me. I’m so glad that I found them!!

Carole S.

Exceptional efficient and professional service from Jay Symonds and Sonia Nogueira. They were both so helpful and knowledgeable and navigated me through a very stressful and difficult situation with New York Life.

K. S.

Awesome team. Jay and his team, Sonia and Francesca, truly care. This team is very Professional and quick to respond. Jay always provided answers in detail to my questions. I strongly recommend Jay Symonds.

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