There have been changes passed for ERISA which go into effect January 2018
The Employee Retirement Income Security Act of 1974 (ERISA) governs most private Long Term Disability insurance plans. The law sets standards for insurance plans. For example, ERISA requires insurers to provide participants with a Summary Plan Description describing how their insurance works. ERISA also requires insurers to have an appeals process in place so people who have had their claims denied can have their claim reevaluated.
Recently, the U.S. Department of Labor released new regulations which affect the appeals process. The new regulations have been published in the Federal Register, but do not apply until January 1, 2018.
The new rules follow the spirit of the regulations enacted in 2015, establishing procedural protections and striking a balance between a claimant’s opportunity to pursue a review and administrative burdens on plans providing benefits. The new rules try to provide disability plan participants with the same sorts of protections afforded to health insurance plan participants.
The new regulations fall under six broad headings:
1. INDEPENDENCE AND IMPARTIALITY—AVOIDING CONFLICTS OF INTEREST
These provisions prevent insurance companies from incentivizing their adjusters to deny claims. They also prevent insurance companies from selecting medical experts based on their reputations for producing unsupportive peer reviews.
If you have been denied long term disability you may still qualify for benefits. Contact an experienced long term disability lawyer at 512-454-4000
2. IMPROVEMENTS TO DISCLOSURE REQUIREMENTS
While ERISA already requires insurers provide a reason for their denial in a written notice in manner calculated to be understood by the claimant, many insurers do not comply with the existing law. New regulations will require more detailed explanations for disagreeing with healthcare providers or vocational experts. Denial letters will now also include instructions for ordering an administrative record. Insurers will be required to reveal any internal guidelines or rules relied upon in making their determination. Denial letters must be provided in the claimant’s language.
3. RIGHT TO REVIEW AND RESPOND TO NEW INFORMATION BEFORE FINAL DECISION
These new regulations will allow claimants to present their case at the administrative level rather than having to wait for a denial and allow the claimant to respond to evidence over the course of the appeal rather than having to wait for a decision. Additionally denial letters will be required to include the date Statute of Limitations runs on the claim.
4. DEEMED EXHAUSTION OF CLAIMS AND APPEALS PROCESSES
Generally, applicants must exhaust their appeals before they are allowed to sue the insurance company. However, this new regulation will allow applicants to sue their insurer before their administrative appeals are exhausted if the insurer fails to comply with claims procedures.
5. COVERAGE RESCISSIONS—ADVERSE BENEFIT DETERMINATIONS
These regulations make recessions of coverage (cutting off benefits) subject to the same appeals procedures as a denial of benefits.
6. CULTURALLY & LINGUISTICALLY APPROPRIATE NOTICES
These rules require that the insurance company provide notices in the language of the applicant upon request.
The new rules will hopefully help ensure Long Term Disability applicants are provided with a fair review of their claim.
Many insurance companies act unscrupulously, denying obviously disabled people the benefits they paid for. If you have been denied Long Term Disability benefits, then you are already aware of how difficult it can be to deal with insurance companies. Get a dedicated long term disability lawyer on your side. Call the Law Office of Bemis, Roach and Reed today for a free consultation. Call 512-454-4000 and get help NOW.
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