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The Department of Labor Issues New Rules for Long-Term Disability Insurance Providers

Posted in Long Term Disability. Tuesday, May 02nd, 2017

Recently, the Employee Benefits Security Administration (EBSA), which is regulated by the Department of Labor published a series of final regulations regarding how long-term disability claims must be filed in order to comply with the Employee Retirement Income Security Act (ERISA). The new rules could have a significant impact on the claims and appeals filing process, so to learn more about how these changes could affect your claim, please contact a dedicated long-term disability attorney in Columbus who can explain your rights.

Claim Denials

The new rules will apply to all ERISA-qualifying plans that provide disability benefits, which means that most employer-provided plans must comply with the regulations. Although the new rules make a variety of amendments to the claims filing process, the most drastic changes address denied claims. For instance, according to the published rules, decisions regarding claims and appeals must be decided independently and impartially. Specifically banned practices include:

  • Providing bonuses or other incentives based on the number of denials issued; and
  • Contracting with medical experts based on their reputation for achieving certain outcomes in contested cases.

The rules now also require adjudicators to issue denial letters containing specific information, such as:

  • Why the adjudicator disagreed with the opinion of health care professionals and denied a claim;
  • The claimant’s right to access his or her file; and
  • Whether the company relied upon any internal rules when making its decision.

Finally, denial letters must be culturally and linguistically appropriate. This means that plan administrators may now be required to:

  • Issue letters in a different language;
  • Explain in denial letters (in the recipient’s predominant language) that additional language services are available; and
  • Provide language services to customers.

Failing to comply with these requirements could constitute convincing evidence that a company was negligent in handling a claim, which could make it easier for a claimant to receive his or her rightful benefits.

The Appeals Process

The regulations also make significant changes to the appeals process. For example, if a company denies a claim based on new evidence, the claimant must be given notice and a fair opportunity to respond to it. Only after these opportunities have been granted can a company deny a claimant’s appeal. Furthermore, all appeal denial letters must include specific information regarding how long a claimant has to file a lawsuit in court. Finally, a company’s decision to retroactively rescind coverage will be considered a denial of benefits and will officially trigger the appeals process.

Contact us Today to Learn How an Experienced Long-Term Disability Attorney Can Help You

The new regulations make major changes to the requirements that insurance companies and employers must meet before issuing a denial. Failing to comply with these rules could open these entities up to liability, so if you live in Columbus and have questions about how the new rules will affect your claim, please contact the legal team at the Law Office of Mike Gertner at 614-463-9393 to schedule a free case evaluation with a dedicated long-term disability attorney.