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Text of DOL Proposed Regs: Claims Procedure for Plans Providing Disability Benefits
Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]Link to more items from this source
[Official Guidance]
Nov. 13, 2015

48 pages. "The purpose of this action is to improve the current procedural protections for workers who become disabled and make claims for disability benefits from an employee benefit plan ... Because of the volume and constancy of litigation in this area, and in light of advancements in claims processing technology, the Department recognizes a need to revisit, reexamine, and revise the current regulations in order to ensure that disability benefit claimants receive a fair review of denied claims as provided by law. To this end, the Department has determined to start by proposing to uplift the current standards applicable to the processing of claims and appeals for disability benefits so that they better align with the requirements regarding internal claims and appeals for group health plans under the regulations implementing the requirements of the Affordable Care Act....

"The major provisions in the proposal largely adopt the procedural protections for health care claimants in the Affordable Care Act, including provisions that seek to ensure that: [1] claims and appeals are adjudicated in manner designed to ensure independence and impartiality of the persons involved in making the decision; [2] benefit denial notices contain a full discussion of why the plan denied the claim and the standards behind the decision; [3] claimants have access to their entire claim file and are allowed to present evidence and testimony during the review process; [4] claimants are notified of and have an opportunity to respond to any new evidence reasonably in advance of an appeal decision; [5] final denials at the appeals stage are not based on new or additional rationales unless claimants first are given notice and a fair opportunity to respond; [6] if plans do not adhere to all claims processing rules, the claimant is deemed to have exhausted the administrative remedies available under the plan, unless the violation was the result of a minor error and other specified conditions are met; [7] certain rescissions of coverage are treated as adverse benefit determinations, thereby triggering the plan's appeals procedures; and [8] notices are written in a culturally and linguistically appropriate manner."

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