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New Evidence After Appeal


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Assume a group health plan complies with the ERISA regulations and properly denies a claim and subsequent appeal.

What options are available to the plan and/or participant if new evidence is discovered (post-appeal) that would have impacted the outcome of the decision?

It would seem that the plan may want to reopen the appeal in order to be fair to the participant. On the other hand, it would seem that the plan could be inviting trouble with by reviving a claim that has been properly moved through the claims and appeals procedure-- especially if it involved a claim that would trigger stop-loss reimbursement.

Any thoughts would be appreciated.

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