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What information must disability denial letters include?

Wednesday, October 25th, 2017

When a person in New York needs disability benefits, the reasons why may seem obvious to them. After all, if an injury or illness keeps them from being able to work, they may find themselves losing out on lost wages along with mounting medical bills, and therefore they are in need of financial help. However, sometimes a person’s claim for disability benefits is denied. That being said, when it comes to a denied claim, applicants have rights under federal law.

Back in December 2016, the U.S. Department of Labor issued new rules regarding ERISA disability claims and appeals. These rules took effect on January 18, 2017 and are applicable to disability benefit claims filed starting on January 1, 2018.

Under the new rules, disability benefits plans are required to make sure than any claims filed under the plan are subject to an independent and impartial review. Employment decisions by disability insurance companies cannot be made based on whether or not the employee will deny disability benefits claims.

The new rules also addressed disclosure requirements. In essence, initial and appeal denial letters must contain the following information. It must state the reason for the disagreement of a determination of disability by a third party insurer or the Social Security Administration, as well as the opinion of a health care provider or vocational professional, even if that person’s information was utilized or not.

Also, if the adverse determination was founded on a specific exclusion or limit, the letter must explain the scientific reason for determining so, or it must state that a person can ask for an explanation at no cost. The letter must also state what internal rules and other criteria was utilized when deciding to deny the individual’s claim. Finally, the letter must state that the individual has the right to ask for any relevant documents. Also, in appeal denial letters, not only must it state that individuals can bring a lawsuit under ERISA, it must also state what the time period a person has to do so.

As you can see, while a person has rights when it comes to a denial of disability benefits, federal rules regarding this topic can be complicated. Those who have questions about a denied claim may want to consult with an attorney who can provide legal advice on ERISA disability appeals, which this post does not provide.

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