New ERISA Regulation Provides Powerful Tool to Protect Claimants’ Rights to Obtain Benefits

O’Ryan Law firm has extensive experience representing clients in appeals and litigation under the Employee Retirement Income Security Act of 1974 (ERISA), which governs most claims for benefits under employer-sponsored insurance plans. Earlier this year, the US Department of Labor amended its regulations under ERISA, providing claimants with some additional rights during the process of appealing denials of benefits under plans governed by ERISA.

One important additional right granted under the new ERISA regulation is the opportunity to review and respond to any additional evidence considered by an insurance company during an appeal of a benefits claim denial. This means that if a claimant appeals a denial or termination of benefits and the insurance company sends the file to a reviewing physician, the claimant has a right to read and respond to the report of that reviewing physician before the insurance company can make its final decision on the appeal. O’Ryan Law firm recently took advantage of this new protection to obtain short term disability (STD) benefits for a client who had previously had her STD benefits terminated.

Kim M was a Repair Service Attendant at a large telecom company and was forced to stop working in early 2017[1] as a result of failed back syndrome, multilevel degenerative disc disease, lumbar facet arthritis, and spondylopathy. After she was unable to return to work, she was awarded STD benefits under her employer’s disability plan, which was administered by Sedgwick. However, Sedgwick terminated Kim’s STD benefits several months later, claiming there was no longer sufficient medical evidence to support her claim. In the letter explaining its termination of Kim’s benefits, Sedgwick relied on the opinions of two reviewing physicians who asserted that Kim was not disabled.

O’Ryan Law Firm assisted Kim in gathering additional medical records and support for her claim and filed an appeal with Sedgwick on her behalf, explaining why the two reviewing doctors’ opinions were critically flawed and insufficient to terminate Kim’s benefits. After receiving the appeal, Sedgwick contacted both reviewing doctors to obtain updates to their reports. When Sedgwick submitted these reports to O’Ryan Law Firm pursuant to the requirements of the new ERISA regulation, we responded with a letter pointing out several critical flaws and glaring inconsistencies that rendered the updated reports unreliable.

Sedgwick next brought in three new reviewing doctors on appeal, each of whom also concluded that Kim was not disabled. O’Ryan Law Firm responded with a letter refuting these reports and explaining why each was critically flawed and unreliable. In response to this letter, Sedgwick submitted addenda from one of the original reviewing physicians and two of the three reviewing physicians who had been brought in on appeal. We submitted another letter responding to these addenda and again explaining why each was critically flawed and unreliable.

Three days after receiving the third letter from O’Ryan Law Firm refuting the medical reviews they had submitted in the appeal process, Sedgwick granted the appeal and awarded Kim the full amount of STD benefits, despite having five reviewing physicians who had unanimously concluded that Kim was not disabled.

Without the opportunity to review and respond to the additional medical reviews on appeal, Sedgwick likely would have simply denied Kim’s appeal in reliance on the new medical reviews. However, because the new ERISA regulation provided an opportunity to explain to Sedgwick why these reviewing doctors’ opinions were critically flawed and unreliable, we were able to use that opportunity to obtain full benefits for Kim on appeal.

In the hands of experienced ERISA attorneys like those at O’Ryan Law firm, the new ERISA regulation is a powerful tool to protect claimants’ rights to obtain the benefits they deserve. If you are disabled and have been denied benefits, please contact the O’Ryan Law Firm for a free consultation.

[1] The new ERISA regulation only governs claims made after April 1, 2018. However, although it was not technically required to do so, Sedgwick processed Kim’s appeal using the standards set forth in the new regulation.