Yes, it does if your claim is governed by ERISA. ERISA – the Employee Retirement Income Security Act – is the federal law that regulates employee benefits offered by private employers. This includes disability benefit and insurance plans that you get through work, if you work for an employer other than a government entity or a church.
The administrator – usually an insurance company – has to follow the law when they deny an ERISA Disability claim. That means they must comply with the United States Code passed by Congress (29 U.S.C. § 1133) and the U.S. Department of Labor’s ERISA regulations (specifically, 29 C.F.R. § 2560.503-1(f)). The claim regulation is very detailed about what the disability insurance company / ERISA administrator must state in a denial letter. Specifically, 29 C.F.R. § 2560.503-1 (g) states:
(g) Manner and content of notification of benefit determination.
(1) Except as provided in paragraph (g)(2) of this section, the plan administrator shall provide a claimant with written or electronic notification of any adverse benefit determination. . . . The notification shall set forth, in a manner calculated to be understood by the claimant –
(i) The specific reason or reasons for the adverse determination;
(ii) Reference to the specific plan provisions on which the determination is based;
(iii) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;
(iv) A description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under section 502(a) of the Act following an adverse benefit determination on review;
(v) In the case of an adverse benefit determination by a group health plan or a plan providing disability benefits,
(A) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other with the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other similar criterion will be provided free of charge upon request. . . .
One reason the administrator has to tell you this information is to allow you to appeal. Under ERISA, you will be required to appeal any denial at least once before you can file a lawsuit. By giving you this information, you know what you are appealing, and you and an ERISA Disability Attorney can focus the appeal on the specific reasons the claim was denied.
John Tucker is an ERISA Disability Attorney based in Florida. If you would like a free consultation about your ERISA Disability claim, contact an ERISA Disability Attorney.