ERISA “Full & Fair Review” & the Missing Pieces of the ADMINISTRATIVE RECORD

One of the most important pieces in a long-term disability case is the “administrative record.” The administrative record is defined as: everything that the insurance company considered in the denial of your claim. It also includes any appeal that you might submit, and any response from the insurer.

Prior to the filing of an appeal, the insurance company must supply a copy of the administrative record as a matter of law. The law regarding administrative records is contained at 29 C.F.R. 2560.503-1. That regulation states that any document that is “generated” in the denial of a claim should be part of the administrative record.

Frequently we evaluate an administrative record and find that multiple problems are present. Here are just a few examples:

1. MetLife refuses to give a copy of its policy to the claimant. It insists that the policy be obtained directly from the employer.
2. Nearly every insurer fails to identify whether the physicians they hire are employees, independent contractors, or paid reviewers.
3. And most insurance companies refuse to turn over bills and invoices for work that these medical doctors perform.

After so many long-term disability cases, it can be said freely that large insurance companies like Liberty Life & Unum do not keep track of the amount of time that their “employee” physicians spend on a file. Likewise, they don’t keep track of individuals that they contract with either.

The problem is aggravated by the activities of review organizations like MLS, PDA & other disability review organizations. These entities generate bills that seem absolutely improbable. When an administrative record has 2000 pages, you would expect that the physician who prepares the report would have 8-10 hours invested in the case. Frequently, we see summaries of bills that only charge for 3 hours of doctor time, and 4 hours of administrative time. The clear implication here is that non-physician employees at these “review” companies are summarizing the evidence and transmitting it to physicians for review.

*Doctors may not be reviewing your actual medical records*

Courts, when confronted with these issues, are hesitant to allow discovery. That trend has to stop. Some courts have a bias toward believing the insurance company doctors. The relationships that exist between review organizations, physicians, & long-term disability insurance companies needs to be explored. After all, when was the last time you read a 2000 page book in 4 hours?? Never!

Insurance companies need to put more into administrative records before they send them out to claimants and their attorneys. The law requires it, and common sense mandates it. The whole object of ERISA is to provide the claimant with a full and fair review.

How can a full and fair review ever take place when so many items are either missing, or are deliberately hidden by insurers?

 

Questions about your long term disability insurance claim?

 Call (877)-428-9806 and we will be happy to answer your questions or concerns.