Re: RIN 1210-AB39

I wish to to comment on the proposed regulations issued by the 

Department of Labor (“Department”), Employee Benefits Security 

Administration on November 18, 2015 (“Proposed Regulations”).

I commend the Department for their proactive step in putting forward 

these positive and much-needed changes. I agree with and fully 

support the rationale of the Department for making this proposal. As 

noted by the Department in the preamble to the Proposed Regulations, 

“disability claimants deserve protections equally as stringent as those 

that Congress and the President have put into place for health care 

claimants under the Affordable Care Act.”

I am a disabled individual who has been affected by practices allowed 

by the Employee Retirement Income Security Act of 1974 (“ERISA”), 

which heavily favors insurance companies over claimants. I have some 

experience of the potential and actual abuses occurring under the 

current claims-procedure regulations and agree that there is an urgent 

need to address these in the Proposed Regulations.

Here are the items that stand out to me, and my reasons for 

supporting the changes.

1) Medical experts may not be hired based on their reputation for 

outcomes in contested cases rather than based on their expertise.

and 2) Claims adjudicators and medical experts may not be hired, 

compensated, terminated or promoted based on the likelihood of their 

denying disability benefits or supporting the denial of such benefits.

Discussion: Some of the most devastating aspects of my claim for 

benefits were the responses of the claim adjustor and doctor hired by 

the insurance company to review my claim. Despite my personal 

doctor's extensive and detailed documentation of both the evidence of 

my disability and its impact on my functional capacity (just the list of 

my limitations was 2 pages long - addressing in detail every 

conceivable aspect of work- and non-work related activity), both the 

adjustor and the doctor hired by the insurance company declared that 

no evidence was presented establishing disability nor limits on 

functional capacity. Although my lawyer later laughed about it because 

he was aware of how blatantly the insurance companies are allowed to 

misrepresent cases, I was dumbstruck. As a person of integrity, who 

trusted the insurer to help when I needed it, I had no idea they were 

allowed to simply lie, or that the companies could (and do!) hire 
adjustors, doctors, and purported experts based on their willingness to 

deny claims. I know of patients who have committed suicide after 

being desperately ill and denied benefits by decisions of insurance 

company doctors who have never seen them, or who dismiss 

compelling evidence because they are paid to do so. The stress of 

being desperately ill and without resources is crushing. Being denied in 

this fashion is abusive and in some cases endangers lives. Doctors 

take an oath that says "First, do no harm." Your proposal to end this 

practice is most needed.

3) The notice of claim denial must include a discussion of the decision, 

including the basis of disagreement with a disability determination by 

the Social Security Administration or a treating doctor.

4) The notice of claim denial must include a statement that the 

claimant is entitled to receive—at that stage and not only at the later 

stage of denial of the appeal—all relevant documentation supporting 

the denial of the claim.

5) The notice of claim denial must include internal rules, guidelines, 

protocols, standards or similar criteria of the plan that were used to 

deny the claim.

Discussion: When I applied for Social Security Disability Insurance 

(“SSDI”), my claim was approved on the first attempt, without any 

denial or delay. The evidence and support that I provided to the Social 

Security Administration (“SSA”) were identical to the materials sent to 

my long-term disability (“LTD”) company. The LTD company never 

explained why they denied my claim despite SSA's approval, even 

when they knew that my SSDI claim had been approved. No 

discussion of the rationale or basis of denial was given, nor clues as to 

what additional evidence may have been desirable. This denial was 

cited as being based on the evaluation of the insurance company 

doctor described in the previous example, a doctor who had never 

seen me and who apparently simply disregarded copious evidence that 

the SSA found compelling. These proposed changes would allow 

claimants to have a clearer understanding of the process as well as a 

better grasp of what is needed for appeal, and the chance of appeal 

being granted. I see these as very positive and important.

6) Claimants must be given the right to review (free of charge), and 

respond to, new or additional evidence or rationales for denial 

considered, relied upon or generated during the appeal process and 

not only after the claim has been denied on appeal. The 
information would have to be made available as soon as possible and 

sufficiently in advance of the deadline and the plan would be obligated 

to consider the claimant’s evidence and written testimony in response 

to the plan’s new or additional information before making a decision on 

appeal.

Discussion: This seems extremely important to me. Under the current 

rules, claimants have no opportunity to review, and respond to, new 

evidence or new rationales used by the insurance companies during 

the appeal process. Under the new rules. claimants would have a 

meaningful opportunity to address such new evidence and rationales, 

making it much more likely that a legitimate claim will be approved 

upon appeal and sparing claimants having to go to court.

7) If the LTD plan has not followed all procedural rules (except in 

cases of minor errors), a claimant may proceed straight to court 

without first exhausting all administrative remedies.

and 8) If the LTD plan has not followed all procedural rules, the 

reviewing court will consider the matter de novo.

Discussion: Far too many claimants have been held hostage to the 

insurers' tactics of delays and denials to basically wear the claimant 

down so they go away and stop pursuing benefits they're owed. These 

two changes would help considerably in curtailing those tactics. 

Particularly removing the standard of accepting the plan's 

determination in court seems much more favorable to the claimant. 

The insurance companies have had it their way under the guise of 

protecting themselves from fraud for far too long. The real fraud could 

be considered selling benefits the companies have no intention of 

providing.

I also support the broadening of the definition of "adverse-benefits 

determination" as proposed, to protect claimants from being denied 

benefits for inadvertent errors.

The simple truth is, most people who find themselves disabled have 

never had to deal with the process of securing benefits. They (we!) are 

severely compromised in our ability to represent ourselves effectively 

because of the constraints of being disabled. The Proposed 

Regulations, if enacted, would give disability claimants more 

procedural rights and safeguards to partially offset the current unfair 

advantage held by insurance companies. As a member of a large class 

of disabled people, many of whom have been denied benefits due to 

these disadvantages and the way they have been leveraged by the 
insurers, I feel strongly that the proposed changes will increase the 

fairness of the situation for people who contract in good faith to 

receive benefits, and through no fault of their own end up being nearly 

abused by the very companies they pay to help them.

Disabled people, including myself, have been faced with a disturbing 

and unethical level of resistance and manipulation by these companies. 

My attorney explained to me that insurers are basically allowed to lie, 

delay, and deny without cause-- without fear of penalty or damages 

being awarded to claimants, without the risk of a jury trial, and 

because the law's structure gives preference to the word of the 

insurance company over the claimant. The Proposed Regulations put 

forth by the Department go some distance toward rectifying this 

situation.

Thank you for taking the time to read my comments.