Administrative Process in ERISA Cases
The "administrative process" is the period from when a disability claim is first filed to when it is either approved or, after all administrative appeals have been exhausted, a final denial has been issued. It necessarily precedes the litigation phase.
It is during the administrative process that all of the medical evidence you are planning to submit to the plan administrator must be submitted. Most courts will allow submission of evidence up to the date the appeal has been formally denied. This is usually at least 45 days beyond the appeal submission date. At that point, the administrative record (or "claim file') is "closed," and, while there are certain exceptions, you will not be able to submit any additional medical evidence.
Evidence from lay persons may be submitted in the form of signed statements under oath, if they are credible and relevant to a claimant's impairments as to activities of daily living (from family members) or impairments at work (from co-workers).
It is also during the administrative period that the plan administrator, in issuing a final denial, must set forth all bases for that denial.
It is during the administrative process that a claimant has the opportunity to obtain the relevant plan documents that govern eligibility for and payment of disability benefits. You must send a written request for the Plan Documents to the Plan Administrator, who is required to provide them (without cost) within 30 days, under 29 U.S.C. § 1024(b)(4), or pay a penalty of $110.00 for each day the documents are not provided.
The Plan Administrator is usually the employer of the claimant and the sponsor of the disability plan. You can verify the name of the plan administrator by checking Form 5500, which is required to be publicly filed, at www.freeerisa.com.
Plan documents should include a Summary Plan Description (SPD), as required by 29 U.S.C. § 1022. Sometimes there will only be an SPD and no formal Plan Document. However, if both a Plan Document and an SPD exist, it is important to obtain the Plan Document. If there is any conflict between the Plan Document and the SPD, courts will enforce the terms of the Plan Document. Cigna Corp. v. Amara, 131 S. Ct. 1866 (2011).
Requests for the administrative record must be made in writing to the insurer, or the third party administrator (TPA), as it determines eligibility, makes benefit decisions, and pays benefits.
Under 29 C.F.R. 2560.503-1(m)(8), you are entitled to all documents relevant to your client's claim for benefits.
Under 29 U.S.C. § 1024(b)(4), a document is "relevant" if it:
(1) Was relied upon in making the benefit determination;
(2) 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;
(3) Demonstrates compliance with the administrative processes and safeguards required pursuant to paragraph (b)(5) of this section in making the benefit determination; or
(4) 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.
ERISA law is very strict as to missed deadlines. Even if a claimant misses a deadline by one day, he/she may be denied the opportunity to further pursue the claim.
However, if a deadline hasn't been blown, but time is running late for an appeal, you can request an extension of time from the claims administrator, especially if the claimant came to you having been previously unrepresented. Most insurers will be careful not to deny a reasonable request to extend time in accordance with their "higher than marketplace" fiduciary obligations. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S. Ct. 243 (2008).
ERISA law is complicated. At Law Med, we are ERISA knowledgeable and experienced.