The Employee Benefits Security Administration (EBSA) announced plans to publish, on November 18, 2015, new proposed claims procedures for handling ERISA-governed disability benefits.  The pdf can be accessed HERE.

Comments are encouraged and must be submitted within 60 days of publication of the proposed new claims procedures.

The proposed new claims procedures apparently will address the following:

(1) claims and appeals procedure;

(2) benefit denial notices, requiring a “full discussion” why the plan denied the claim and the standards behind the decision;

(3) claimants access to their “entire claim file” and how claimants can present evidence and testimony during the review process;

(4) how claimants should be notified of an appeal decision, detailing an opportunity to respond to any new evidence reasonably in advance of an appeal decision;

(5) details related to final denials at the appeals stage. The rules will prohibit decisions be based on new or additional rationales, unless claimants first are given notice and a fair opportunity to respond;

(6) what happens when plans fail to follow claims processing rules: the claimant will be deemed to have exhausted 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) how notices should be written in a “culturally and linguistically appropriate” manner.

 

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Photo of Mike Reilly Mike Reilly

Mike Reilly is a nationally recognized labor, employment and employee benefits attorney, named one of the “Top 100 Most Powerful Employment Attorneys in the Nation” for the past five consecutive years by Human Resource Executive®. He has decades of experience providing strategic employment advice, and has represented clients in more than 75 jury trials, arbitrations, bench trials and claims before the EEOC and Washington State Human Rights Commission.

Small and large employers retain Mike for his strategic advice and decades of experience in employment issues and litigation, business decisions and litigation avoidance. Mike provides advice in claims involving discrimination, retaliation, wrongful discharge, disability accommodation, ERISA and non-ERISA employee benefit claims, and wage/hour claims. He served as lead counsel in an employee raiding/trade secret case as reported in the Wall Street Journal, and defends employers in class action claims.

Mike’s remarks on employment issues have been quoted in NewsweekCorporate Legal TimesSeattle TimesEmployee Relations Law JournalPuget Sound Business JournalCFO.com, and other professional journals and management publications. Chambers USA’s Guide to America’s Leading Lawyers for Businessrates Mike in the top ranking (band one) for his work in labor and employment law, and has described him as “one of Seattle’s top-rate attorneys” who is “truly phenomenal [with] superb legal instincts” and “an amazingly assertive litigator.” His clients include Nordstrom, Seattle Seahawks, Home Depot, KeyBank, Starbucks, Fred Hutchinson Cancer Research Center, Red Robin and Seattle Chamber of Commerce, among others.