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.