Often, the same disability insurance company that pays your claim for benefits also determines whether it has to pay you benefits at all. Sound like a conflict? It sure is. The insurance company (acting as plan administrator) has an incentive to deny your claim since it will save the insurance company money. The insurance company’s decision that you are not disabled and that you can continue to work is not impartial.
Despite this conflict of interest, courts will not typically reverse benefit denials based on impartiality alone. When an insurance policy grants the administrator discretion to determine your eligibility for benefits, a judge reviewing the lawfulness of the administrator’s decision will consider MANY factors to decide whether the administrator acted reasonably. A court may determine that there was a significant conflict of interest if, for instance, through discovery you are able to prove that the administrator has a history of biased administration. Nevertheless, if the insurance company has supported its decision with medical opinions that show you are not fully disabled, a court will likely uphold the denial of benefits.
If you have been denied disability benefits you will need strong evidence for a court to reverse the administrator’s decision. If you believe you have been wrongfully denied benefits, please call Hawks Quindel, S.C. for a free consultation.