In an ERISA case, at the center of any dispute over a claimant’s eligibility for long-term disability benefits is the administrative record.
The administrative record is legalese for all the medical records, documents and other information obtained by, and submitted to, the plan administrator during the initial stages of the claim and through the appeal process.
One reason the administrative record is so important is that a claimant who challenges a denial of long-term disability benefits by filing a court action generally cannot present evidence to the court that is not in the record. Another reason is that disability insurers and plan administrators can—and will—take information from the administrative record out of context to justify denying a claim for disability benefits.
Here is a real-life example: A claimant filled out an “Activities Questionnaire” for her plan administrator and answered questions about her abilities. In the questionnaire, the claimant reported that she walked two miles a week on an underwater treadmill. One key advantage of the underwater treadmill is that it can make it easier for a person experiencing joint pain to walk because the water diminishes the pounding on the person’s knees, hips and neck. In addition, the person can hold onto the handlebars of the treadmill for support. Given these features, it is much easier to walk on an underwater treadmill than on a sidewalk or around a high school track.
The plan administrator denied the claim. In its letter explaining why it rejected the disability claim, the plan administrator specifically mentioned that the claimant was able to walk two miles a week, while neglecting to point out that she did so on an underwater treadmill. This omission was obviously self-serving because it gave an exaggerated depiction of the claimant’s abilities and condition.
In another example, a plan administrator, in its denial letter, noted that the claimant’s physician reported that her condition “stabilized.” That was, in fact, true. What the denial letter omitted is that the claimant’s physician also supported her disability claim on the basis that her condition, even after it had stabilized, prevented her from meeting the demands of her job. The physician’s comment that the claimant’s condition stabilized should not have mattered; however, the plan administrator used it to justify its denial of long-term disability benefits.
What is the takeaway here? To paraphrase the Miranda Warning, anything claimants put in the administrative record can and will be used against them. Claimants, therefore, should be careful about how they fill out their disability paperwork. Be detailed in what you provide to the plan administrator because any description of your abilities that is incomplete or ambiguous will not be construed in your favor.
For example, if you live in a one-bedroom apartment and state in your questionnaire that you are able to do household chores, make sure you clarify that you do not reside in a home, but in a one-bedroom apartment. State, specifically, that you live in a one-bedroom apartment, and underline that fact. The plan administrator may still take your comment out of context, but at least you will have laid the foundation for a successful administrative appeal, or court challenge.
Even in non-ERISA cases, disability insurers will manipulate a claimant’s incomplete statements in a way that helps them justify a denial of benefits. Often, they will pose written questions to claimants that, unbeknownst to the claimant, have legal significance, and are artfully worded to elicit responses helpful to the plan administrator. That is why it is important to consult with a disability insurance lawyer early in the claims process.