Difficulties Involving ERISA Claims for Subjective-Proof Diseases Subjective-Proof Diseases said:
Conclusion
Diseases evidenced by subjective proof are inherently impossible to prove objectively, and therefore are difficult to address on judicial review. The standard of review that courts employ in these appeals is that of “abuse of discretion,” which is heightened if there is a conflict of interest, which there often is. This conflict of interest arises because the insurer is both the administrator of the plan and the payor of benefits if the claimant succeeds in their application. Even with a heightened “abuse of discretion” standard, claimants whose diseases are evidenced by subjective proof are not guaranteed a full and fair review of their claims. Plan administrators may simply deny claims and then argue that the denial was justified due to a lack of objective evidence on appeal. While they are not always successful, with today’s judicial scheme, it is more likely than not that the plan administrator’s denial will be upheld.
Increasingly, insurance plan language discriminates against claimants with subjective-proof diseases. “Self-Report” clauses and those that deny any form of relief for these illnesses are against public policy and should be disallowed by federal legislation. To provide that an employee must have objective evidence of his disease contradicts modern medicine’s recognition of many debilitating diseases that do not have medical tests for diagnosis. If an employee is provided coverage by his employer or buys long-term disability coverage independently, plan administrators should not deny his claim because his plan has unfairly excluded his disease. These self-report clauses are against public policy and Congress should mandate an exclusion from long-term disability plans covered under ERISA. ERISA’s goal to protect the rights of employees goes against the coverage provided in many of these plans, and these contradictions should not be allowed.
By altering the standard of review or disallowing clauses biased against subjective-proof diseases, a claimant’s right to full and fair review will be ensured. Just because objective tests do not evidence these diseases does not mean they are any less disabling. Ensuring a claimant receives full and fair review guarantees that the employee’s rights are upheld and plan administrators do not unfairly deny their claims.
