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ERISA Disclosure Requirements and Appeal of Denied Claim
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ERISA Disclosure Requirements and Appeal of Denied Claim
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My employer, who is self-funded and self andministered for disability, recently denied my claim for disability benefits despite having previously approved it. My claim was denied based on a sham "inde
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Forums » Topic Forums » Legal Forum » ERISA Disclosure Requirements and Appeal of Denied Claim
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ERISA Disclosure Requirements and Appeal of Denied Claim
posted at 7/16/1999 7:38 AM EDT
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Posts: 2
First: 7/12/1999 Last: 7/16/1999 |
My employer, who is self-funded and self andministered for disability, recently denied my claim for disability benefits despite having previously approved it. My claim was denied based on a sham "independent" medical evaluation where they selected and paid the evaluator. He spoke with me for less than an hour, did not conduct a psychiatric evaluation, only asked general questions and I KNOW that he did not even review my medical records, but nevertheless decided I could go to work. The person who informed me of the denied claim (and received the IME) is my immediate supervisor.
I wrote my employer and asked them for a written explanation of why the claim was denied as well as a copy of the Independent Medical Evaluation. They called me and said they did not usually give this information to participants. I reminded them that, under ERISA, I have a right to review pertinent documents related to my claim as well as submit a written response. I also provided them with my doctor's address and fax number in case they preferred to send the information to my doctor. They then said that if my doctor and the IME doc couldn't agree on a return to work date, they would send me to a third doctor. It has been over a week and I and my doctor have gotten no response whatsoever. I informed them that I was not returning to work yet because my treating physician disagrees with the IME doc and thinks a return to work at this state would cause a tremendous setback and a severe relapse. They have taken no action to terminate me so far. They have also not sent me the IME Report. My guess is that a) there is something in the IME report they don't want me to see b) they have decided not to fight this because I am such a tremendous pain in the ass and it's dawning on them that there might be some legal liability here or c) they're consulting legal counsel and this is the calm before the storm. I have two questions: 1) If they do not provide the materials I requested within 30 days, do I have a right to file suit in federal court to get them? I can't even take steps to appeal the denial unless I know what was in the IME. 2)If they want to send me to a second "independent" doctor (i.e. on their payroll), do I have to go, or can I choose my own doctor? If I choose my own, how do I go about this? By definition an "independent" doctor is simply one who isn't the treating physician (I looked it up). By sending me to another one of their docs, they would really be stacking the deck against me. Sorry for the long post. Any suggestions, referrals to other sources or information is appreciated. Thanks! |
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