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 26 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 23, 2016
Health and Welfare Law
Final Regulations for Disability Benefit Claims Procedures
has issued final regulations governing the claims procedures
requirement for ERISA-covered plans that provide disability
benefits. In particular, the final regulations require
applicable plans to satisfy additional procedural and notice
requirements for disability claims. The regulations apply to
disability claims filed on or after January 1, 2018.
Background. ERISA requires employers to provide
adequate notice to a plan participant whose benefit claim has been
denied, and to provide the participant a full and fair process for
review of the claim denial.
Where an ERISA-covered plan provides a benefit that is payable only
upon a showing of disability, that benefit is subject to the DOL's
disability claims regulation. The final regulations establish
certain new requirements for employers to satisfy their compliance
obligations under ERISA.
Final Regulations. The final regulations add
the following procedural requirements to the disability benefit
of Coverage Procedures.
Plan administrators must treat certain rescissions of coverage as
adverse benefit determinations. (Note: A
rescission of coverage occurs when a plan administrator terminates a
participant's coverage retroactively.) As a result,
participants may now appeal rescissions of coverage. However, a
rescission based on the participant's non-payment of premiums is not
an adverse benefit determination.
Denial Notices. Benefit
denial notices must:
- Provide a
more detailed description of the reason for the claim
denial. For example, in relevant cases, the notice must
explain why the plan administrator disagrees with the opinions
of the participant's health care professionals or the Social
Security Administration's determination of disability.
- Be written
in in a linguistically and culturally appropriate manner, and
explain that oral language services are available to the
participant. Similarly, the plan administrator must
explain to participants that they are entitled to receive, upon
request, any notice relevant to the determination in the
applicable non-English language.
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
Access to New Evidence. During any appeal process, 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. To meet this
requirement, plan administrators must ensure that the employer does
not make employment decisions (i.e., hiring, firing,
promotions, etc.) believing that such action will support the benefit
denial. Moreover, plans cannot provide bonuses on the basis of
denials made by claims adjudicators.
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