Who gets the last word in an ERISA claim appeal?

The ERISA statute requires claimants whose benefit claims have been denied to file a pre-litigation appeal before seeking relief from the federal court. The law requires that claimants receive a "full and fair" review of the denial of benefits. But what does that mean?

A recent federal court ruling, Hughes v. Hartford Life and Accident Insurance Co., 2019 WL 1324947 (D. Conn., March 25, 2019), addressed the question of whether claimants get to respond to adverse evidence developed by the insurer during the course of a claim appeal. This has been a controversial issue for years; and claimants have complained that without having the opportunity to review and comment on adverse evidence, license is being given to insurers to sandbag claimants since it can often be difficult to introduce rebuttal evidence once litigation commences. In Hughes, the court acknowledged the inconsistency between the notiion of a full and fair review and the benefit plan's ability to withhold evidence.

For claims filed after April 1, 2018, this will no longer be a problem because 29 C.F.R. Section 2560.503-1(h)(4)(i)) mandates that benefit plans share data with insureds. However, the full effect of that regulation will not be felt for at least one year. Hughes clarifies that until that day arrives, fairness dictates that claimants be given the last word during the claim appeal process.

I authored an article on the case that was published in the Chicago Daily Law Bulletin on April 11, 2019; and a copy may be found at https://www.debofsky.com/Articles/Defining-full-and-fair-review-of-disability-benefits-claim.shtml.