Articles Tagged with “ERISA disability”

Most disability insurance policies do not explicitly require that a claimant provide objective evidence to support their disability. Yet, it is all too common when a claimant receives a denial letter in the mail from their insurance company claiming that disability benefits have been denied due to a lack of objective evidence. Unfortunately, many courts have determined that insurance companies are permitted to rely upon objective evidence when making a determination of disability.

Objective medical evidence is documentation from tests including but not limited to: medical resonance imaging (MRIs), x-rays, blood tests and other chemical tests, electrophysiological studies (electrocardiogram, electroencephalogram, etc.), and psychological tests. Unfortunately, not all medical conditions are detected in these various types of objective testing, which can put some disability claimants in a challenging condition. For example, someone with fibromyalgia may not be able to produce traditional objective medical evidence of their condition. For more information about fibromyalgia, see this entry: Fibromyalgia Disability Claims.

In order to improve the chances of being approved for disability insurance benefits, a claimant should make sure that their treating providers have ordered all of the necessary tests to properly diagnose their condition. Without objective documentation, the insurance company is much more likely to deny benefits. For example, a claimant with Multiple Sclerosis should undergo any applicable testing, like an MRI of the brain, a spinal tap, and tests measuring electrical activity in the brain. For more information about Multiple Sclerosis, see this entry: Multiple Sclerosis Disability Claims.
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ERISA was enacted to promote the interests of employees and their beneficiaries in employee benefit plans and to protect contractually defined benefits. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 829 (2003). An ERISA plan is a “special kind of contract,” in which there exists a “presumption of full judicial review at the behest of the [plan participants or beneficiaries].”Fritcher v. Health Care Service Corp., 301 F.3d 811, 816 (7th Cir. 2002). Full disclosure of important rights and responsibilities under ERISA plans was a primary goal in the enactment of ERISA. In endorsing ERISA, the Congressional Committee on Education and Labor considered fiduciary duty and disclosure an “essential element” of employee plans. H.R. Rep. 93-533, p. 4645-4646 (October 2, 1973). The Committee specifically stated that disclosure requirements under the prior Welfare and Pension Plans Disclosure Act were insufficient and had not accomplished Congressional intent:

Experience has . . . demonstrated a need for a more particularized form of reporting so that the individual participant knows exactly where he stands with respect to the plan– what benefits he may be entitled to, what circumstances may preclude him from obtaining benefits, what procedures he must follow to obtain benefits, and who are the persons to whom the management and investment of his plan funds have been entrusted.

Id. at 4649. In order to strengthen and improve the protection of participants in employee welfare benefit plans, ERISA was passed in 1974. Congress specifically recognized the importance of disclosure of information and transparency in welfare benefit plans, which includes providing plan participants with clear information regarding whether third party administrators have been given discretionary authority to make claims determinations.