By Pension and Benefits Editorial Staff
Authorized representatives may act on behalf of plan participants and beneficiaries, under benefit claims procedure regulations, concerning initial claims for benefits and appeals of adverse benefit determinations, according to a Department of Labor (DOL) information letter.
A company acting as a patient advocate and healthcare claim recovery expert for plan participants and beneficiaries, both at the initial application stage and when claimants appeal adverse benefit determinations, requested clarification from the DOL of its ability to act as an authorized representative for claimants under the DOL claims procedure regulations.
The DOL notes that ERISA Reg. §2560.503-1 provides the minimum requirements for employee benefit plan claims procedures under ERISA. ERISA Reg. §2560.503-1(b)(4) 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. In addition, DOL FAQ guidance confirms that authorized representatives are entitled to notifications in connection with initial claim determinations and appeals.
The DOL explains that, although a plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant, the plan procedures cannot prevent claimants from choosing for themselves who will act as their representative or preclude the claimants from designating an authorized representative for the initial claim, an appeal of an adverse benefit determination, or both. Also, the DOL notes that plans must include any procedures for designating authorized representatives in the plans’ claims procedures and in the plans’ summary plan descriptions (SPDs) or a separate document that accompanies the SPDs. SPDs must include a statement that plan claims procedures are furnished automatically, without charge, as a separate document.
SOURCE: DOL Information Letter.
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