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The Wagner Law Group

The Wagner Law Group is a nationally recognized practice in the areas of ERISA and employee benefits, estate planning, employment, labor and human resources and  investment management.

 

 

Established in 1996, The Wagner Law Group is dedicated to the highest standards of integrity, excellence and thought leadership and is considered to be amongst the nation's premier ERISA and employee benefits law firms. The firm has six offices across the country, providing unparalleled legal advice to its clients, including large, small and nonprofit corporations as well as individuals and government entities worldwide. The Wagner Law Group's 28 attorneys, senior benefits consultant and three paralegals combine many years of experience in their fields of practice with a variety of backgrounds. Seven of the attorneys are AV-rated by Martindale-Hubbell and six are Fellows of the American College of Employee Benefits Counsel, an invitation-only organization of nationally recognized employee benefits lawyers.  Seven of the firm's attorneys have been named to the prestigious Super Lawyers list for 2016, which highlights outstanding lawyers based on a rigorous selection process.

 

 

 

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

 

Washington, D.C.

Tel: (202) 969-2800

  Fax: (202) 969-2568

800 Connecticut Ave., N.W.

Suite 810

Washington, D.C. 20006

 


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

300 Montgomery Street

Suite 600

San Francisco, CA 94104

 

St. Louis

Tel: (314) 236-0065

Fax: (314) 236-5743
25 W. Moody Avenue
St. Louis, MO  63119

 

 

www.wagnerlawgroup.com

 

 

 

August 17, 2017

 

 Health and Welfare Law Alert

 

 

 

 DOL to Review Disability Claims

Procedure Regulations

 

 

 

 

DOL recently announced that it will review ERISA's disability claims procedures regulations for questions of law and policy to determine if they should be amended, delayed, or withdrawn.  The regulations, which were finalized in December 2016 and slated to take effect for claims made on or after January 1, 2018, require covered plans to satisfy additional procedural and notice requirements for disability claims.

 

 

Background.  ERISA requires covered plans to maintain an internal review and appeals procedure for the settlement of claims for benefits.  Typically, if a plan contains these procedures, a court will be deferential to the claim determination made by the plan administrator.  When a plan does not contain such claims procedures, courts may review a claims decision without providing any deference to the plan administrator's determination. 

 

 

ERISA's disability claims procedure regulations apply to health and welfare plans and retirement plans that: (i) condition the award of benefits on a finding of disability; and (ii) require the employer to make the disability determination.  However, the regulations do not apply to any plan that provides a benefit conditioned on the finding of disability made by a third party other than the plan.  

 

 

Final Regulations.  The final regulations added the following procedural requirements to the disability benefit claims process:

 

  • Rescissions of Coverage Procedures.  Plan administrators must treat certain rescissions of coverage as adverse benefit determinations. 
  • Benefit Denial Notices.  Benefit denial notices must provide a more detailed description of the reason for the claim denial and be written in  a linguistically and culturally appropriate manner.
  • Explanation of Claims Procedures. Plan administrators must explain the protocols that were used to determine the participant's benefit claim.
  • Access to Claims File.  Plan administrators must inform participants, in benefit denial notices, that they are entitled to access, free of charge, all documents relevant to the adverse claim determination.
  • Access to New Evidence.  Plan administrators must provide participants with any new evidence being considered by the plan during the appeal process.
  • Conflicts of Interest.  Plan administrators must make benefit determinations in a manner that ensures independence and impartiality of the decision-makers involved in the process. 

 

For more information on these requirements, see the Alert of 12/22/2016.

 

 

 

Takeaway for Employers.  An announcement of this nature is fairly uncommon so it is likely, but not a certainty, that DOL will delay and/or amend the final regulations.  In the wake of DOL's announcement, employers that sponsor plans covered by the regulations must choose between the following two options:

 

  1. Proceed with amending their plans to implement the new requirements or provide that the determination of disability be made by a third party (thereby exempting the plan from the regulations).
  2. Wait to implement any changes until the future of the regulations becomes clearer.

 

The final regulations are available for review at: https://www.gpo.gov/fdsys/pkg/FR-2016-12-19/pdf/2016-30070.pdf

 

 

 

 

 

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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.