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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 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.

 

 

 

 

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

300 Montgomery Street

Suite 600

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 23, 2016

 

 Health and Welfare Law Alert

 

 

 

   DOL Releases Final Regulations for Disability Benefit Claims Procedures 

 

 

 

 

 

The DOL 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 claims process:

 

Rescissions 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.

 

Benefit 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 determinations.

 

 

 

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.

 

 

 

The final regulations are available 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.