Final Regulations Issued on Claims Procedures for Disability Plans

The Department of Labor has issued final regulations for disability benefit claims governed by ERISA.  The regulations are summarized as follows:

1. Claims and appeals must be adjudicated in a manner designed to ensure independence and impartiality of the persons involved in making the benefit determination.
2. Benefit denial notices must contain a complete discussion of why the plan denied the claim and the standards applied in reaching the decision, including the basis for disagreeing with the views of health-care or vocational professionals or with the disability benefit determinations of the Social Security Administration.
3. Claimants must be given timely notice of their right to access their entire claim file and other relevant documents and be guaranteed the right to present evidence and testimony in support of their claim during the review process.
4. Claimants must be given notice and a fair opportunity to respond before denials at the appeals stage are based on new or additional evidence or rationales.
5. Plans cannot prohibit a claimant from seeking court review of a claim denial based on a failure to exhaust administrative remedies under the plan if the plan failed to comply with the claims procedure requirements, unless the violation was the result of a minor error.
6. Certain rescissions of coverage are to be treated as adverse benefit determinations triggering the plan’s appeals procedures.
7. Required notices and disclosures issued under the claims procedure regulations must be written in a culturally and linguistically appropriate manner.

These regulations are effective for all claims filed on or after January 1, 2018.

If you have questions about these final regulations, call ASR Health Benefits at (616) 957-1751 or (800) 968-2449.