The Department of Labor recently strengthened the procedural safeguards governing claims for disability benefits provided by employee benefit plans. The new regulations are designed to ensure that all claims and appeals for disability benefits are given a full and fair review. For example, an adverse benefit determination must include: (1) an explanation of the basis for the decision; (2) an explanation of the scientific or clinical judgment underlying the adverse determination or an offer to provide such explanation free of charge; (3) the rules, guidelines or other criteria within the benefit plan relied upon to deny benefits; (4) a statement that the claimant is entitled to receive upon request and free of charge copies of all records, documents and other information relevant to the claim for benefits; and (5) a description of the applicable appeal procedures. A failure to comply with these disclosure requirements may result in the claimant’s right to seek immediate relief in federal court.
On the other hand, the information provided by the plan administrator may reveal a need for additional documentation to support the claim before initiating litigation. In light of these new regulations and the resulting access to relevant information, every denial of a claim for disability benefits should be closely and promptly reviewed to determine the best course of action.