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ERISA Regulations for Claims and Appeals Recently Updated

ERISA regulations apply to claims for long-term disability benefits with insurance companies. The regulations are known as Claims Procedures, and they apply to any disability benefits claims that are governed by ERISA.

In December 2016, the ERISA regulations were updated by the Department of Labor. The new regulations will take effect on or after January 1, 2018. Any plan that provides for disability insurance benefits and falls under ERISA will be affected by these new regulations. These new ERISA regulations will be very beneficial to people applying for disability benefits from insurance companies, adding protections to the claims and appeals process.

To begin, the new ERISA regulations will require the insurance company to decide all claims and appeals independently and unbiased. There can be no motives (usually financial) for denying a claim. Medical experts and vocational experts hired by the insurance company must be non-biased. Meaning, a medical expert or vocational expert cannot be used because they usually find in favor of the insurance company.

Next, the ERISA regulations will now require more information to be provided in the disability benefits denial letters. The insurance company must explain why they did not agree with the medical or vocational expert’s’ opinion that supported your disability. Additionally, they must explain why they did not agree with the Social Security Administration determination of disability (if applicable). The letter must also include any of the insurance company’s rules, policies, or regulations that were relied upon in making in their determination. Lastly, the disability benefits denial letter must give you an explanation of your right to access to your claim file and other documentation.

The new ERISA regulations must give you an opportunity to “review and respond to new information.” For example, assume your appeal denial is based on a reason different from the initial reason given for the claim denial. You will now have a right to respond to the new reason. You may do this by providing additional information or documentation supporting your claim.

The last major point in the new regulations deals with a violation of ERISA law in the disability insurance plan or policy. If the plan or policy does not follow the law in terms of claims procedures, then you could sue under ERISA. Typically, you have to appeal, which is also known as exhausting all administrative remedies, under the plan before you can file a lawsuit. However, under the new regulations, if the plan does not meet ERISA requirements for claims procedures, you will have been considered to have met all requirements and can file a lawsuit right away.

The new ERISA regulations are a positive step for anyone filing a claim under their ERISA disability policy. Although the regulations will not take effect until January 2018, insurance companies are encouraged to start changing their policies and plans to meet the new requirements.

Even with these new regulations, filling for a disability benefits claim or appealing a denial is a complicated process. Having an experience disability insurance attorney help you through it can make a huge difference in the outcome. The experienced disability insurance attorneys at Dabdoub Law Firm are familiar with all stages of the claims process. Taking into consideration the new regulations, they can ensure you get the most out of the your disability insurance policy.