Medical Record Ping-Pong

Have you ever played a game of ping-pong? The game where you hit the ball back and forth? A somewhat frustrating development in the world of disability insurance appeals has emerged due to the recent revision of the federal regulation implementing ERISA, the federal law that governs most long-term disability claims, 29 CFR § 2560.503-1. The revision requires a disability insurer that denies long-term disability benefits to provide a copy of the medical evidence, on which the denial was based, to the insured for a response before the insurance company renders a final decision. While this may sound like a good thing, and was certainly intended to be, in practice it means that after the ERISA claimant provides an application for disability insurance benefits, and the benefits are denied, each letter denying the claim will be accompanied by a new report from the ERISA administrator to which the ERISA claimant gets another period of time to respond – potentially forever.


In the typical process of a long-term disability appeal, the claimant (or legal counsel) submits the appeal (ideally with additional or supporting medical evidence) and the file is transferred from the claim manager who denied the claim to the appeals department to review the file again. The person who reviews your file from the insurance company forwards the file to a physician who reviews the file and provides an opinion as to whether you are disabled. If that physician concludes you are disabled, your benefits are usually paid. If not, under the old regulation, the insurer issued a final denial which could proceed to federal court under the ERISA statute. Now, the insurer provides a denial letter along with a new medical opinion with a deadline for any response the insured would like to provide – and that response will be met with yet another decision – an approval – or, at this stage, far more likely, (since the case has already been denied once) another denial with yet another medical record with yet another deadline to respond.


Just remember that once your doctors respond, the insurance company will send those responses and/or additional medical records over to the physician originally used to review and respond as well. It is like a game of ping-pong. At some point, the ERISA claimant should ask for a final decision. If you find yourself playing medical opinion ping-pong with a disability insurance company, an ERISA long-term disability attorney can be of assistance. Call Cremeens Law Group PLLC at 813-839-2000 today for a free evaluation of your case.