the new "DOL Benefit Claims Procedure Regulations"

[Moe Howard]

Do the new ERISA "medical claims deadlines" that the DOL requires a plan's insurance company to follow ... have to be described in the Summary Plan Description ?

It seems that the SPD wording might have to be quite lengthy to fully explain the new regulations.

Medical insurance companies must now process medical claims faster than before. The fact that there is now a separate set of DOL rules for each of three types of claims (urgent health care, pre-certification health care, and post-service health care) will make the SPD more difficult to write.

Can anyone direct me to a SPD on the internet that has this new disclosure ?

Thanks

[Guest chloe]

While the Claim/Appeal Rule does not expressly require language in the SPD, the ERISA SPD Rule has always required that the claim and appeal procedures be included in the SPD. This was clarified in the most recent revision of that rule effective 1/20/2001. (see 29 CFR 2520.102-3(s)) Additionally, state laws would require that the SPD include specific claim and appeal language that complies with each state law. It is a cumbersome task, but you should be able to meet the requirements in about 6 pages. Unfortunately, I can't show you any sample language.

[jeanine]

We did it in less than 4 pages. We were able to avoid repeating ourselves for each type of claim by using a chart for the time frames by type of claim then using the same verbiage to describe the process.

[Moe Howard]

Does anyone know how the DOL may penalize an insurance company that does not comply with the new claim regulations ?

I have read the DOL new claim procedure regulations over and over .... and they make no reference as to what might intice an insurance company to follow the regs.

[jeanine]

The only "penalty" I understood was that the failure to have an appeals process that followed ERISA requirements would result in the determination that the enrollee had exhausted the appeals process and could move on to federal court where the judge could apply a de novo standard of review. I had some questions on this as well--mostly what to do when your state insurance law required a different appeals procedure. We were told (informally) that as far as the insurance department was concerned, an insured enrollee was entitled to both appeals processes.

The DOL regulations really don't apply to the insurance company. They apply to the Group Health Plan regardless of whether the Plan provides benefits through the purchase of an insurance policy or self-funds the benefits. It is conceivable that the responsibilities of the group health plan will not be met by the insurance company.