Health Reform WK-EDGE DOL confirms patient advocate’s right to act as claims procedure representative
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Thursday, March 28, 2019

DOL confirms patient advocate’s right to act as claims procedure representative

By Tulay Turan, J.D.

The claims procedure of an ERISA-covered plan cannot preclude the representative of a claimant from acting on behalf of the claimant to pursue a benefit claim or appeal an adverse benefit determination.

The Department of Labor (DOL) has issued an information letter addressing the ability of a patient advocate and health care claim recovery expert for plan participants and beneficiaries to act as an authorized representative for claimants in accordance with the department’s claim procedure regulation, which implements ERISA Sec. 503 (DOL Letter, February 27, 2019).

The DOL indicates that the claims procedure of an ERISA-covered plan cannot "preclude an authorized representative of a claimant from acting on behalf of such claimant in pursuing a benefit claim or appeal of an adverse benefit determination." In addition, prior department guidance on the claims procedure regulation confirms that authorized representatives are entitled to notifications in connection with initial claim determinations and appeals.

Right to appoint representative. The claims procedure regulation at ERISA Reg. §2560.503-1 sets forth minimum requirements for employee benefit plan claims procedures under ERISA. Subparagraph (b)(4) of the regulation expressly gives participants and beneficiaries the right to appoint authorized representatives to act on their behalf in connection with an initial claim for benefits as well as an appeal of an adverse benefit determination.

Reasonable procedures. The DOL indicates that although a plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant, the procedure cannot prevent claimants from choosing for themselves who will act as their representative or preclude them from designating an authorized representative for the initial claim, an appeal of an adverse benefit determination, or both.

The plan must include any procedures for designating authorized representatives in the plan’s claims procedures and in the plan’s summary plan description (SPD) or a separate document that accompanies the SPD. SPDs must satisfy the style and format requirements for SPDs in ERISA Reg. §2520.102-2 and include a statement that the plan’s claims procedures are furnished automatically, without charge, as a separate document.

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