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It is Critical to Have the Documents Governing a Benefits Claim Before Filing a Claim.

Whether you are insured under an individual insurance policy that you obtained on your own, or a participant under a group benefit plan that was provided to you as a benefit of your employment, it is critical to have a copy of the documents governing your benefits claim before contacting the insurance company or other administrator regarding your claim for benefits. The documents, whether individual insurance policy or group plan benefit documents, are legally significant and contain the terms by which your benefits claim should be reviewed and determined.

If you are covered under an individual insurance policy, and you do not have a copy of the insurance policy in your possession, you should be able to obtain a copy through contacting your insurance agent. It is very important that any policy provided to you be the complete policy, including any riders which can modify entire portions of the contract or add benefits, such as a cost of living increase to your benefit amount on an annual basis, extending the maximum benefit duration, adding a waiver of premium benefit rider, or the like. It is further important that the policy reflect the benefit amount in place at the time of your insurance benefit claim, which likely could have increased since the time you initial purchased the policy and began paying premiums. A copy of any policy provided should include a copy of your application for that policy. Be sure to review the insurance policy document provided to you very carefully to ensure that it is consistent with your understanding of the insurance coverage for which you paid premiums and to ensure that the insurance policy document is complete. 

If you are covered under an employer-provided group benefits plan, which was promised to you as a benefit of your employment, obtaining a copy of the documents governing your employee benefit is quite different. Most employer-provided group benefits plans are governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). While ERISA law has had the perverse effect of providing much less protection to employees and their employee benefits that what Congress intended in enacting the legislation, there are still very clear requirements as to information that must be provided to an employee regarding an employee benefit governed by ERISA. For instance, the employer providing the employee benefit is usually considered the Plan Administrator, and thus is the party responsible to maintaining a true and correct copy of the Plan documents governing your employee benefit. The Plan Administrator is required under ERISA to provide an employee with what is called a summary plan description (SPD) when the employee becomes a participant under an ERISA-governed group benefit plan. This must be provided free of charge, and it is required to include certain information about how the employee benefit plan is operated, information on when the employee can begin to participate in the employee benefit plan, how service and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file a claim for benefits and to appeal a denial of benefits, the contact information for the Plan administrator and other important information. If an employee benefit plan is ever changed, all participants in the employee benefit plan must be informed (free of charge), either though being provided with a revised summary plan description, or in an adequately drafted separate document. It is critical that the summary plan description in your possession is the most updated summary of the group benefit plan at issue at the time that your right to the group benefit claim arose. Often times employers change the terms of the employee benefit offered to their employees, or change an insurance company that may insure the employee benefit which in turn changes the terms of the benefit  (i.e., some employee benefits are self-funded by the employer, and some are insured by an insurance company for which the employer and/or the employee pays a group premium rate). Many times employer do not adhere to the strict notice requirements under ERISA and fail to provide proper notice that the benefit has changed. Thus, it is important to ensure that you have the correct version of the summary plan description prior to pursuing any claim for benefits. Also, upon written request to the Plan Administrator, an employee is entitled to receive a full copy of the plan document free of charge. The plan document contains much more information than the summary plan description, which is only a summary of the plan terms and not the full plan document that legally governs any benefit claim. It is again critical that the plan document provided be the correct version that was in place at the time that the right to file the benefit claim arose. For example, with a group disablility benefit, this would depend on the employee/participant's date of disability.  For a life insurance benefit, it would depend on the date of the employee/participant's death. For a long-term care benefit, it would be dependent upon the date when the employee/participant became qualified to receive a long-term care benefit (based upon an inability to perform a certain amount of activities of daily living, or meeting the threshold for benefits related to cognitive impairment, etc.). The Human Resources Department of your employer providing the employee benefit at issue is usually a good place to start in obtaining a copy of your employee benefit plan. However, keep in mind that any information given to your employer by you in requesting this information will likely be documented, and it may be taken into consideration by the party (including the employer or any insurance company) ultimately making the decision as to your entitlement to benefits. Thus, the importance of how and what information is presented at critical time periods cannot be understated.

Your insurance policy or group benefit plan documents are dense with legally significant terms, definitions, and provisions which are generally confusing and open to interpretation from both the covered individual's perspective and the insurance company's (or other benefit administrator's) perspective. Having notice of the terms, and the position taken with regard the terms of the documents governing the insurance or employee benefit and what they mean is essential to proving entitlement to the benefit at issue and to preventing the insurance company from getting away with unfair interpretations of the terms to deny a benefits claim. Furthermore, the insurance company or other administrator may argue that different or additional policy terms apply to your benefit claim than what you are able to confirm applies per your policy or plan documents. Or the company may refuse to honor a term despite the term being contained in the policy or plan documents provided to you. Without the policy or plan documents in your possession, you may not even be aware this is occuring and certainly you won't have the information to adequately dispute such tactics.  We have regularly had situations arise involving disputes of the proper policy or plan documents that should govern a claim for benefits (which literally mean the difference of an approved or denied claim), and also enforcing our clients rights to being provided with certain information and policy documents under the law. We are also regularly retained by clients before they file their claim for benefits, and handle ensuring that we (and our clients) are in possession of the correct and complete policy and plan information prior to filing any claim for benefits given the critical importance of developing a claim for benefits in a way that takes into account the terms at issue (some of which may be problematic for our clients in obtaining benefits). Should you have any questions or concerns as to your right to copies of the policy or plan documents or other information related to your insurance or employee benefit claim, or your rights under such policy or plan documents as they are written, please contact one of our experience attorneys for a free consultation.

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