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The Wagner Law Group

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established 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.

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Boston 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Palm Beach Gardens 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

Tampa

Tel: (813) 603-2959

Fax: (813) 603-2961

101 East Kennedy Boulevard

Suite 2140
Tampa, FL  33602 

 

San Francisco

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104

 

St. Louis

Tel: (314) 236-0065

Fax: (314) 236-5743
100 South 4th Street, Suite 550
St. Louis, MO  63102 

 

www.wagnerlawgroup.com

 

 

 

 

December 3, 2015

 

 Health and Welfare Law Alert

 

 

 

  DOL Issues Proposed Regulations Implementing ACA Protections for Disability Claims

 

 

 

The DOL 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.

 

 

DOL 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. 

 

 

In 2010, 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 the decision.
  • Benefit denial notices must contain a full discussion of why the plan denied the claim and the standards behind the decision.
  • Claimants must have access to their entire claim file and be allowed to present evidence and testimony during the review process.
  • Claimants must be notified of, and have an opportunity to respond to, any new evidence reasonably in advance of an appeal decision.
  • Final 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.
  • Claimants 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 of noncompliance.
  • Certain 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 manner.

 

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 benefits.

 


The final regulations are available at:
http://www.gpo.gov/fdsys/pkg/FR-2015-11-18/pdf/2015-29295.pdf

 

 

 

This Newsletter is protected by copyright. Material appearing herein may be reproduced with appropriate credit.

 

This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.