DOL Proposes Changes to ERISA
In prior posts, we have noted that employer-sponsored disability plans are generally governed by ERISA. We have also discussed some of the challenges claimants may face when filing a disability claim under ERISA.
Recently, the Department of Labor (DOL) proposed some new regulations that could make filing a disability claim under ERISA more claimant-friendly. If finalized, the regulations will change several aspects of the claims process under ERISA. Some of the most notable changes are as follows:
- Insurers will have to hire medical experts based solely upon professional qualifications (as opposed to hiring an expert because the expert is known for supporting disability denials of benefits).
- At both the initial claim stage and the appeal stage, insurers will have to provide a detailed explanation for their denial, including their bases for disagreeing with the claimant’s treating physician, the Social Security Administration, and/or other insurers who are paying benefits under other policies the claimant may have.
- Insurers will have to include the internal rules/guidelines/protocols/standards used to deny the disability claim, or expressly state that such criteria do not exist.
- Insurers will have to notify claimants at the initial claim phase that the claimant is entitled to receive and review a copy of their claim file (right now, insurers only have to do this at the appeal stage).
- During the appeal stage, insurers must automatically provide claimants with any new information that was not considered at the initial claim stage so that the claimants can review and respond to the new information.
- If an insurer violates the new rules (and it is not a minor violation) claimants can file suit immediately and the court must review the dispute de novo (i.e. without giving special deference to the insurer’s claim decision).
Some of these rules have already been established by case law, but as of right now, they are not uniformly applied across the country. If the DOL moves forward and finalizes the regulations, disability insurers and plan administrators will have to uniformly comply with these new rules when administrating ERISA claims.
