Health Plans - Enrollment Appeals and ERISA guidelines

[Guest akwallace]

Do the same ERISA guidelines that apply to claim appeals (72 hours, 90 days, etc.) apply to enrollment appeals?

If an employee does not enroll within 31 days of the date of hire, for example, and wants to enroll, does the employer have to adhere to specific guidelines for such an appeal?

[Guest BenefitsLawyer]

DOL addressed this in its informal guidance issued as Q&As on 12/17/01. (The URL at that time was http://askpwba.dol.gov/faq-claims-proc-reg.html, but it has undoubtedly changed--I hope you'll be able to track it down from there, though.) Q3 is: "Does the [claim] regulation apply to a request for a determination whether an individual is eligible for coverage under a plan?" The relevant part of A3 is: "If an individual asks a question concerning eligibility for coverage under a plan without making a claim for benefits, the eligibility detrmination is not governed by the claims procedure rules. If, on the other hand, the individual files a claim for benefits, in accordance with the plan's reasonable procedures, and that claim is denied because the individual is not eligibile for coverage under the plan, the coverage determination is part of a claim and must be handled in accordance with the claims procedures of the plan and the requirements of the regulation. See 65 FR at 70255." Hope this helps.

[Guest lsh]

Here is the new link to Q&A 3

http://www.dol.gov/ebsa/FAQs/faq_claims_proc_reg.html