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How to Fight ERISA Plans With Free Information

By Jeffrey Herman

 

Getting denied insurance benefits is stressful. So is going through an appeal. But having to deal with a meddling and difficult insurance company on top of all that? That just makes it worse.

 

But you are not powerless in the appeals process. You have rights. The most significant of which is the right to request, free of charge, all relevant information concerning your claim.

 

Let me say that again: the insurance company has to give you everything relevant to your insurance claim. For free. By law. (Specifically, 29 C.F.R. §§ 2560.503-1(h)(2)(iii) and (j)(3), but you don't need to know that.)

 

So if the insurance company refuses to provide something, don’t let them get away with it. Tell them it’s your right. If they still refuse, then that’s something that can help if you end up having to file a lawsuit down the road.

 

What is relevant information?

 

Your right to free, relevant information covers pretty much anything that does or could affect your claim, in whatever form. Specifically, you are entitled to:

  • Anything the insurance company relied on when deciding your claim;
  • Anything the insurance company submitted, considered, or generated, even if the insurer did not rely on it;
  • Anything that shows the insurer is trying to comply with your insurance plan’s requirements;
  • Anything that shows the insurer is trying apply your plan consistently with similar claims; and
  • For disability or health insurance claims, statements of policy or guidance with respect to the plan “concerning the denied treatment option or benefit for the claimant’s diagnosis,” even if the insurer claims it did not follow its own policies in your case.

 

These five categories can encompass A LOT of information. For example: copies of any video recordings they took of you (which happens, unfortunately); a copy of your insurance plan; copies of expert reports they obtain, and those experts’ CVs; how much they paid their experts; their claims handling manuals or training guides for their employees; and more.

 

And the information can be a document, a record, or anything else, like recordings or other electronic information.

 

Armed with this information, you can more successfully fight your appeal. The insurance company will have no tricks up its sleeve. Everything will be on the table.

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