By Carol Potaczek
The Employee Benefit Security Administration (EBSA) has proposed to delay the applicability of final regulations revising the claims procedures for employee benefit plans providing disability benefits, which were originally published on December 19, 2016. The Final rules had adopted certain procedural protections and safeguards for disability benefit claims that were already applicable to claims for group health benefits under the Patient Protection and Affordable Care Act (ACA) (Proposed rule, 82 FR 47409, October 12, 2017).
The Final rules were scheduled to apply to claims for disability benefits under ERISA-covered employee benefit plans that are filed on or after January 1, 2018. Under the proposed delay, the rules would be applicable claims filed after April 1, 2018. The EBSA states that, following publication of the final rules, various stakeholders and members of Congress expressed concerns that the rules would drive up disability costs and cause an increase in litigation, thus impairing workers’ access to disability insurance benefits. Therefore, the EBSA is giving the public an additional opportunity to submit comments and data concerning the potential impact of the final rules.
Revisions in Final rules. Major provisions in the final rules require that: claims and appeals be adjudicated in a manner designed to ensure independence and impartiality of the persons involved in making the benefit determination; benefit denial notices must contain a complete discussion of why the plan denied the claim and the standards applied in reaching the decision; claimants must be given timely notice of their right to access to their entire claim file and other relevant documents and be guaranteed the right to present evidence and testimony in support of their claim during the review process; claimants must be given notice and a fair opportunity to respond before denials at the appeals stage are based on new or additional evidence or rationales; plans generally cannot prohibit a claimant from seeking court review of a claim denial based on a failure to exhaust administrative remedies under the plan if the plan failed to comply with the claims procedure requirements; certain rescissions of coverage are to be treated as adverse benefit determinations triggering the plan’s appeals procedures; and required notices and disclosures issued under the claims procedure regulation must be written in a culturally and linguistically appropriate manner.
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