It is important for any claimant to know his or her rights under ERISA in making a long term disability claim. Section 1133 of ERISA reads as follows: “In accordance with regulations of the Secretary, every employee benefit plan shall - (1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and (2) afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.” 29 U.S.C. § 1133. Accordingly, one significant right is that an ERISA decision-maker must provide a claimant with specific reasons for its denial or termination of benefits or that decision-maker will be found to have acted in an arbitrary and capricious manner. See also, Harlick v. Blue Shield of California, 686 F.3d 699, 720 (9th Cir. 2012); Mitchell v. CB Richard Ellis Long Term Disability Plan, 611 F.3d 1192, 1199 n. 2 (9 th Cir. 2010) (quoting Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 689 (7th Cir. 1992), and Jebian v. Hewlett- Packard Co., Employee Benefits Org. Income Prot. Plan, 349 F.3d 1098, 1104 (9th Cir. 2003)). In other words, a decision-maker – usually, but not always, an insurance company – cannot play “hide the ball.” ERISA and its implementing regulations are undermined “where plan administrators have available sufficient information to assert a basis for denial of benefits, but choose to hold that basis in reserve rather than communicate it to the beneficiary.” Mitchell v. CB Richard Ellis Long Term Disability Plan, 611 F.3d 1192, 1199, n.2 (quoting Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113, 129 (1 st Cir. 2004). Indeed, ERISA and its accompanying regulations “were intended to help claimants process their claims efficiently and fairly; they were not intended to be used by [an insurance company] as a smokescreen to shield itself from legitimate claims.” Short v. Central States, S.E. & S.W. Areas Pension Fund, 729 F.2d 567, 575 (8th Cir. 1984) (quoting Richardson v. Central States, S.E. & S.W. Areas Pension Fund, 645 F.2d 660, 665 (8th Cir. 1981)); Halpin, 962 F.2d at 696.
However, it is not uncommon for an insurance company to conceal its true reason for stopping or terminating benefits until it issues its final denial such that a claimant has no opportunity to rebut this new argument. If you find yourself in this situation please know that the insurance company has acted improperly and you still have rights that can be vindicated in a court of law.