Court Rules Insurer Cannot Withhold Relevant Claim Documents

The denial of a disability claim can be incredibly frustrating and confusing for claimants. Insurers typically provide only vague reasoning for the decision, leaving claimants in the dark to figure out why they were denied and what steps they should take to appeal the decision. They are advised of the deadline and procedure for appealing the denial, but often don’t know where to start.

If the claim was made under an ERISA plan, the denied claimant is entitled to request a complete copy of their claim file, which will contain “all documents, records, and other information” relevant to his or her claim. 29 CFR 2560.503-1(h)(2)(iii). It should include any and all internal notes, memos, correspondence, and reviews/reports by third parties, allowing the claimant to thoroughly understand the insurer’s decision-making. The insurer has a continuing obligation to provide an updated claim file on request throughout the appeal process.

Although ERISA regulations define “relevant” broadly, insurers frequently take it upon themselves to decide which documents do, and do not, need to be shared. Most of the time, the documents they withhold are helpful to the claimant. The recently-decided case of Jette v. United of Omaha Life Insurance Company, 18 F.4th 18 (U.S. 1st Cir. 2021) provides one example.

During the appeal of Jette’s long-term disability claim, United required her to undergo an in-person examination with a doctor of their choosing. United’s doctor agreed with Jette’s treating physician, and issued a report that supported her ongoing disability. United ignored his report and upheld the denial of Jette’s claim. She did not receive a copy of the report until after the final denial, when she no longer had the right to respond to it.

Jette filed a lawsuit. United defended its decision to withhold the report, claiming that it was not “relevant” because they had not relied upon it in deciding to deny her benefits. The First Circuit Court of Appeals disagreed.

The Court noted that the statutory definition of “relevant” includes anything that was “submitted, considered, or generated in the course of making the benefit determination”, regardless of whether the insurer relied on it. 29 CFR 2560.503-1(m)(8)(i)-(ii). Because the report was generated in the course of United’s determination, Jette was entitled to review and respond to it as part of her “meaningful dialogue” with her insurer.

Disability insurers have a legal obligation to perform their duties “solely in the interest of the [plan] participants and beneficiaries” and for the “exclusive purpose of providing benefits [to them.]”  29 U.S.C. §§ 1104(a)(1)(A) & (B). When an insurer withholds documents which would tend to support the disability claim, they act wrongfully to their own benefit. The Jette decision makes clear that insurers cannot unilaterally decide what information and/or documents are relevant for inclusion in the claim file. If it exists, it must be disclosed.

If your claim is denied, you should be sure to obtain your entire claim file and review it carefully to confirm that it contains every document relevant to your claim.

Handing a disability claim can be very difficult. We at Bonny G. Rafel LLC, provide legal counsel to individuals seeking to obtain (or overcome a denial of) long term disability benefits, and advocate for our clients as the Voice of the Disabled.  See our website for video presentations and information on our boutique practice and contact us to discuss your case.

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