Back in 2016, the Department of Labor created new regulations to change the disability benefits claims review process covered by the Employees Retirement Income Security Act (ERISA) of 1974. Although claimants expected these rule to take effect on January 1, 2018, due to a delay they did not take effect until April 1, 2018. If you have an ERISA plan, you should know how these new rules could affect any future disability claim that you might file.

Why Implement New Disability Claims Rules

There’s a simple reason for these changes. Section 503 of the ERISA contains regulations that provide detailed instructions concerning the claims process. These instructions include information on notice requirements, time frames, qualifications, notice content, and more. As a result of these regulations, claims made under group health plans and disability plans must now meet higher standards.

When the Affordable Care Act (ACA) passed, group plan claims procedures experienced enhancements; however, disability plan procedures did not change.

Following these enhancements, the Department of Labor decided to update the regulations concerning ERISA disability plans as well, especially after finding that most of ERISA’s plan litigation was the result of long-term disability claims.

The New Disability Claims Rules

ESRA-covered plans that provide disability benefits will need to make changes to the way disability benefits claims receive reviews and determinations. This in turn could affect your ability to qualify for disability benefits. Changes made include:

• Claim denials must include an explanation detailing the reason the plan disagreed with the Social Security Administration or health care professional’s view.
• The claim denial must include a statement declaring that the claimant can request more information. They must also have reasonable access to all records, documents and other relevant information regarding the claim, free of charge.
• If the claim denial is a final internal denial, then a statement must be included. That statement must detail the right of the claimant to appeal the decision. The statement must also include any contractual limitation periods. Limitation periods apply to the right to bring such an action forward.
• Claim denials based on the claimant’s medical necessity or experimental treatment must have an explanation. Or, any clinical reasons for denial/a statement offering to provide an explanation upon request must be included.

More Changes

• Retroactively canceled coverage must fall under claim denials unless premiums or contributions towards the cost of coverage were not paid on time.
• The decision to hire, terminate, promote or compensate individuals pertaining to a claim, such as a vocational expert or a claims adjuster, cannot take effect based on whether the plan thinks the individual will support the denial of a claim.
• The claimant must receive notice for the rationale and any new or additional evidence used to determined benefits. This must occur before a claim appeal has been officially denied so that the claimant has time to respond.
• Claim denials must include the specific internal rules, protocols, standards or guidelines used to deny the claim; this includes if a lack of such criteria was behind the denial.
• The claimant has the right to proceed to litigation if the plan does not adhere to these new claim procedures.

These new changes will actually benefit claimants. Although, employers will need to make sure that all ERISA covered plans that provide disability benefits are in compliance. For more information on how these new disability claims rules could affect you, schedule a free consultation by calling SSDA USA at 602-952-3200 or by using our online LiveChat feature.

This is attorney advertising. SSDA, LLC is a group of attorneys that pursues claims for Social Security Disability benefits on behalf of its clients against the Social Security Administration. SSDA, LLC is in no way a part of the Social Security Administration. Further, the information on this blog is for general information purposes only. Nothing herein should be taken as legal advice. This information is not intended to create, and receipt or viewing does not constitute, a representative-client relationship.