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The things the insurance company may not tell claimants about their rights under ERISA

There are many things that an administrator or insurance company may not tell claimants about their rights in ERISA benefit claims and ERISA appeals (when there has been a denial of their ERISA benefits). Just a few of the many things that the insurance company may not reveal to claimants about their ERISA rights includes:

•· A claimant is entitled to receive copies of ERISA plan documents from the administrator. A claimant (otherwise known as a participant or beneficiary under ERISA) is entitled to receive a copy of the employee benefit plan document, whether a disability, life, health or other type of employee benefit governed by ERISA, upon written request to the plan administrator of the benefit. This includes any summary plan description or policy document for the particular benefit.

•· The time period required for an ERISA claim determination to be made by the administrator is required by federal regulation. The administrator who is responsible for reviewing an individual's benefit claim (insurance company, employer, etc.) is required to make a determination as to whether it will pay or deny benefits and inform the claimant of the determination made within a certain amount of calendar days. The amount of calendar days (including weekends and holidays) that an administrator has to make the claim determination varies according to the type of employee benefit at issue.

•o Disability benefit claims. Disability benefit claims must be decided within a reasonable period of time, but not later than 45 days after the administrator has received the claim for benefits. Only if there are reasons beyond the control of the administrator that the give rise to a need for more time for the administrator to make a claim determination is the administrator allowed an extension of time, and the extension of time is limited to 30 days. The administrator must tell the claimant prior to the end of the initial 45-day period that additional time is needed, and it must explain to the claimant why any unresolved issues and additional information is needed, as well as advise when the administrator expects to make a claim determination. Any extensions of time outside of the rules governing ERISA require a claimant's consent.

•o Life insurance claims. Life insurance claims must be decided within a reasonable period of time, but not later than 90 days after the administrator has received the claim for benefits. Only if the administrator determines that there are special circumstances (beyond the control of the plan) that require an extension of time for processing the claim is the administrator allowed an extension of time, and the maximum extension of time allowed is 90 days. The administrator must provide written notice of the need for the extension of time prior to the end of the initial 90-day period, and it must indicate the special circumstances that require an extension of time, as well as a date by which the plan expects to render the claim determination.

•o Health benefit claims. Urgent care health benefit claims must be decided as soon as possible, taking into account the urgency of the patient's situation, but not later than 72 hours after receipt of the claim. If there is missing information, the administrator must tell the claimant within 24 hours what information is needed, and the claimant must be given no less than 48 hours to provide the information. The administrator must then make a claim determination within 48 hours after the missing information being provided. The administrator cannot extend the time to make a claim determination without the consent of the claimant. Pre-service claims must be decided within a reasonable period of time under the medical circumstances, but no later than 15 dates after the administrator is in receipt of the claim for benefits, with the ability to extend the deadline by no more than 15 days but only for special circumstances beyond the control of the plan. The administrator must make a determination on a post-service health claim within a reasonable period of time but not later than 30 days after receipt of the clam for benefits. The administrator can extend for up to 15 days, if circumstances beyond the control of the administrator prevent a sooner claim determination.

•· If a group benefit claim is denied, the ERISA administrator must provide the claimant with written or electronic notification of the benefit determination. In other words, the claimant must be provided with a written denial letter in manner calculated to be understood by the claimant. The denial letter must include the specific reasons for the claim denial, as well as reference to any plan provisions upon which the claim denial is based, and a description of any additional material or information necessary for the claimant to provide to the administrator

•· If a group benefit claim governed by ERISA is denied by an administrator, certain information must be provided to the claimant upon written request and free of charge. If an administrator determines to deny a claim for ERISA benefits, it must provide the claimant upon request and free of charge reasonable access to, and copies of, all documents, records and other information relevant to the claimant's claim for benefit. Whether a document, record or other information is relevant to a claim for benefits is determined by the regulation, 29 C.F.R. § 2560.503-1.

•· If an ERISA-governed claim for health or disability benefits is denied, the administrator must identify experts from whom advice was sought by the administrator. When an administrator denies a claim for health or disability benefits, it must provide for the identification of the medical or vocational experts whose advice was obtained on behalf of the administrator in connection with the denial of the benefits claim, without regard to whether the advice was relied upon in making the claim determination.

•· A claimant must file a timely appeal with the administrator when ERISA benefits are denied or the claimant will be barred from pursuing the claim further. If a claimant's claim for ERISA benefits is denied, the claimant must file an administrative appeal directly to the party denying the claim (e.g., the insurance company, the employer) or the claimant will be precluded from pursuing the claim any further into the future. This includes being precluded from ever filing a lawsuit related to the claim. The appeal must be filed within the period of time set by federal regulation or the greater amount of time set by the benefit plan, or the administrator can refuse to consider the appeal, which has the effect of precluding the claimant from pursuing the claim any further. The only way around filing an administrative appeal within the timeframe set by regulation or the plan document is to have the administrator grant an extension of time to file the appeal.

•o Disability benefit claims. Where there is a denial of a claim for disability benefits governed by ERISA, the claimant must file an appeal with the administrator by no later than 180 days following the claimant's receipt of the denial letter. (The minimum amount of time that the claimant must be provided to file an appeal under regulation is 180 days, but the disability benefit plan could allow for more time to appeal).

•o Life insurance claims. Where there is a denial of a claim for life benefits governed by ERISA, the claimant must file an appeal with the administrator by no later than 60 days following the claimant's receipt of the denial letter. (The minimum amount of time that the claimant must be provided to file an appeal under regulation is 60 days, but the life benefit plan could allow for more time to appeal).

•o Health benefit claims. Where there is a denial of a claim for health benefits governed by ERISA, the claimant must file an appeal with the administrator by no later than 180 days following the claimant's receipt of the denial letter. (The minimum amount of time that the claimant must be provided to file an appeal under regulation is 180 days, but the health benefit plan could allow for more time to appeal).

•· An appeal review by an ERISA administrator must involve people independent of the initial denial of the claim for benefits. Where an appeal of a denial of benefits that is filed, the administrator is required to only have individuals who were not consulted in any way during the initial claim review be involved in the appeal review. In other words, the claims representative and any expert consultant (medical, vocational) must be different from those involved in denying the claim for benefits initially, and must also not be the subordinates of any individual involved in denying the claim for benefits initially.

This is just a few of the many things that an ERISA administrator may not reveal to claimants about their ERISA rights.  Please contact one of our experienced ERISA attorneys for a free consultations regarding any questions or concerns that you have about your ERISA benefits claim.

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