When an ERISA case is brought before a federal judge, the administrative record represents the onlyevidence that will be considered. The record contains every form, record, letter, and other type of documentprovided by the claimant or created by the plan administrator, from the filing of the original claim for disability benefits to the final denial of the appeal. Either side can file a motion contesting the inclusion of certain documents, along with a brief explaining the supporting case law. In most cases, however, the administration record contains every piece of information relevant to the disability claim.
- Every document you submit and all other information you provide to your plan administrator will be added to the administrative record;
- Every document submitted and all other information provided by yourdoctor, employer, co-workers, family members, and other relevant parties will be added to the administrative record;
- Your plan administrator will be extremely thorough in collecting evidence that contradicts and discredits your disability claim and adding it to the administrative record;
- Any document or piece of information that you have not provided to your plan administrator during the claims and appeals processes will not be added to the administrative record, and therefore will not be considered by the court in the event of litigation.
- If your case is presented before a federal judge, he or she presumes no knowledge of your professional duties or your condition, and it is your job to educate him or her on both counts.
This is why it is essential that you provide as much specific, detailed information in support of your claim as possible at every stage of the ERISA process. Experienced ERISA attorney J. Price McNamara can help to ensure that your administrative record contains comprehensive evidence of your disability and your right to collect the benefits due to you.
What types of documents are usually included in the administrative record?
In general, the administrative record includes any document available to orreviewed by the plan administrator during the evaluation of your claim, such as:
- The official plan document
- The policy, if different from the plan document
- The summary plan description (SPD)
- Your original claim for disability benefits
- All medical records relevant to your injury
- All correspondence exchanged between you and the plan administrator
- Your job description
- The letter notifying you that your original claim had been denied
- Your appeal letter
- Any further documents you were required to provide with your appeal
- The letter notifying you that your appeal had been denied
- Internal documents generated by the insurance company, including reports, records, results of any surveillance it conducted, and other pertinent data
In order to ensure that your case is fairly represented in the administrative record, it is important that you do not rely exclusively on the forms provided by the insurance company, especially those that require information from your doctor. While it is necessary that your doctor answer the questions contained in these forms, these responses alone will probably not tell your entire story. In fact, these forms generally include very little space for detailed responses, which is no accident. If your doctor does not provide sufficient information regarding your injury and your inability to perform your professional duties as defined by your job description, your plan administrator will have defensible cause to deny your claim or appeal.
How do I provide the strongest possible evidence of my injury?
As you collect evidence of your debilitating injury to present to your plan administrator, keep the following tips in mind:
- The insurance company does not have your best interests in mind, no matter what its representatives might claim.
- You should be as thorough and detailed as possible in describing the duties associated with your job. If your job description is vague or incomplete, your plan administrator will fill in the gaps with information suggesting that you are able to perform your duties and therefore are not entitled to disability benefits.
- Assume that the insurance company has you under surveillance at all times. Don’t participate in any activity against which your doctor advises or that otherwise might contradict your claim for benefits.
- You are not limited in the amount of evidence you can provide supporting your injury and your inability to work. Your plan administrator may suggest that you will be given all of the forms you need to submit your claim or appeal, but this is far from the case. You can include:
- Certified statements from doctors other than your own, as well as other medical specialists.
- The results of any research you have done into your condition, including articles from medical journals and other reliable sources.
- Reports of physical, psychiatric, and vocational rehabilitation evaluations.
While this may seem like a lot of work, you can be assured that the insurance company has the resources to fill the administrative record with substantial and compelling evidence that contradicts yours. In fact, the insurance company is prepared for possible litigation from the moment you submit your initial claim.
An experienced ERISA attorney can take the burden of collecting and organizing all of this evidence off your shoulders and make sure that it is submitted in accordance with the terms of the summary plan description.
ERISA lawyer J. Price McNamara has extensive experience in presenting the strongest cases possible on behalf of injured workers. He can make sure that your evidence measures up to that collected by the insurance company and that the administrative record represents your evidence fairly, accurately, and thoroughly.