Plan administrators are engaged to administer claims on the plan’s behalf, which include determinations of eligibility and denying coverage, among other services. When a claim is denied, the plan administrator is required to provide adequate notice to the participant, among other things. The Employee Retirement Income Security Act of 1974 (“ERISA”) generally requires the notice to include the specific reasons for the denial and to provide citations to the specific plan provisions upon which the denial is based. Two recent cases have scrutinized the sufficiency of the explanations provided in these notices denying coverage.
D.K. et al. v. United Behavioral Health et al:
In D.K., the defendant denied coverage of the plaintiff’s request for long-term treatment for depression, anxiety, and suicidal thoughts. In support of the request, plaintiff submitted medical records and several letters from treating physicians recommending long-term treatment. Despite this evidence, the defendant insurance company denied plaintiff’s request.
The defendant’s denial letter contained conclusory and general statements about the plaintiff’s condition and minimal statements about her treatment to support its denial. The court found that the defendant did not consider the opinions of the plaintiff’s treating physicians when making its decision to deny coverage. In addition, the court determined that the defendant’s denial lacked any analysis because the defendant did not cite any medical records to support its denial. The court further found that not only did the defendant erroneously interpret and apply the terms of the plan, but its rational for denying coverage was also inconsistent between its various denial letters. As a result, the court required the defendant to pay for the plaintiff’s treatment.
Brian J. v. United Healthcare Insurance Co.:
In Brian J., the defendant denied coverage of the plaintiff’s continued treatment for mental health issues. In its denial letter, the defendant indicated that the reason it denied coverage was because the plaintiff’s “symptoms were better”, among other things. The court required the defendant to reconsider whether the plaintiff satisfied the criteria for coverage because the court determined that (1) the defendant’s reasoning for denying benefits contradicted the defendant’s own internal notes and (2) the defendant “did not adequately explain the grounds for its decision.
What Can Administrators and Fiduciaries Do?
To avoid the same follies as the defendants in these cases, the fiduciaries should ask themselves the following questions when preparing a denial:
- Does the denial provide and analyze the specific reasons for denying the claim?
- Are the reasons consistent with the internal notes for denying the claim?
- Are the reasons supported by the plan and the medical records/opinions?
- Does the denial reference this support?
If the answer to any of those questions is “no”, the denial may not be adequate under ERISA.
ERISA requires notices denying coverage of benefits to provide specific reasons and to cite specific plan provisions to support the decision to deny coverage. Plans and administrators should document their reasoning for denying benefits and make sure denial letters not only adequately explain the reasoning for the denial, but also accurately reflect the basis for denying benefits. Courts may require plans that provide notices that are inaccurate, inconsistent, and do not adequately explain the reasons for denying coverage to reconsider coverage or pay for coverage.