The Wagner Law Group
Wagner Law Group, A Professional Corporation, is a nationally
recognized ERISA & employee benefits, estate planning,
employment, labor & human resources practice.
in 1996, The Wagner Law Group has 22 attorneys engaged
exclusively in employee benefits, estate planning and
employment law. Six of our attorneys are AV rated by
Martindale-Hubbell as having very high to preeminent legal abilities
and ethical standards. The firm is among the largest ERISA boutiques
in the country. Our practice is national in scope, with clients in
more than 40 states and several foreign countries.
Wagner Law Group
Fax: (561) 293-3591
7108 Fairway Drive
Palm Beach Gardens, FL 33418
East Kennedy Boulevard
Tampa, FL 33602
Francisco, CA 94104
100 South 4th Street, Suite 550
St. Louis, MO 63102
December 3, 2015
Health and Welfare Law
DOL Issues Proposed
Regulations Implementing ACA Protections for Disability Claims
has issued proposed regulations for adjudicating disability benefit
claims. This proposal would apply many of the procedural
protections and safeguards provided under the Affordable Care Act
("ACA") to disability claims.
Background. ERISA requires employee benefit plans to
provide adequate written notice to any participant whose claim for
benefits has been denied. This notice must: (i) be composed in
a manner calculated to be understood by the participant, (ii) set
forth the specific reasons for the denial, and (iii) afford a
reasonable opportunity to the participant for a full and fair review
of the decision denying the claim.
regulations published in 1977 established certain minimum
requirements for benefit claims procedures for ERISA-covered employee
benefit plans. DOL has subsequently revised and updated these
regulations to improve and strengthen the minimum requirements.
ACA added certain provisions to ERISA that apply to group health
plans, including new requirements for internal claims and
appeals and external review processes. DOL's proposed
regulations make many of these ACA procedural protections applicable
to the internal claims and appeal processes for disability benefits.
Proposed Regulations. The proposed regulations would
incorporate the following ACA procedural protections:
- Claims and
appeals must be adjudicated in a manner designed to ensure the
independence and impartiality of the person involved in making
denial notices must contain a full discussion of why the plan
denied the claim and the standards behind the decision.
must have access to their entire claim file and be allowed to
present evidence and testimony during the review process.
must be notified of, and have an opportunity to respond to, any
new evidence reasonably in advance of an appeal decision.
denials at the appeal stage cannot be based on new or additional
rationales unless claimants are first given notice and a fair
opportunity to respond.
are deemed to have exhausted administrative remedies if the plan
does not adhere to all claims processing rules, unless the
procedural violation was: (i) de minimis, (ii) non-prejudicial,
(iii) attributable to good cause or matters beyond the plan's
control, (iv) in the context of an ongoing good-faith exchange
of information, and (v) not reflective of a pattern or practice
rescissions of coverage are treated as adverse benefit
determinations subject to the plan's appeal procedures.
- Notices must
be written in a culturally and linguistically appropriate
Impact on Employers. Employers are advised to carefully watch
for the development of these regulations. Once they are
finalized, amendments will likely be needed to plan documents for
ERISA-covered pension and welfare plans that provide disability
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