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Navigating ERISA Regulations for Disability Claims

Navigating ERISA Regulations for Disability Claims

Unless you’ve gone off the grid (in which case you aren’t reading this), you’ve likely heard about or have been involved in responding to the new ERISA regulations applicable to disability claims.

The final rule passed by the U.S. Department of Labor (DOL) impacts claims submitted on or after April 1st. The updated regulations require several important changes to disability claim procedures in order to offer additional claimant protections. The regulations apply to benefit plan administrators of group disability and some voluntary disability business, and cover several areas in order to be compliant.

Ensuring you haven’t overlooked or misunderstood any of the requirements may mean seeking guidance from those familiar with the law. Brooks Magratten, a principal at Pierce Atwood, LLP, has been doing the rounds recently to educate insurers and other related parties on what’s behind these requirements. We asked if he would shed some light on this timely topic for our readers.

Below are a few of his key takeaways regarding compliance with the new rule. You can also download his complete analysis here.

What Is Considered an ERISA Plan?

An ERISA plan can be any employee benefit plan sponsored or maintained by a private-sector employer or employee organization.

  • ERISA may not apply to plans of public institutions. For example, plans sponsored or maintained by public schools and state, county or municipal governments are exempted from ERISA.


  • ERISA does not apply to church plans. Exactly what constitutes a "Church Plan" can be a factually intensive inquiry. This determination often depends on how closely an employee benefit plan is affiliated with an organized religion.


  • ERISA may apply to union plans. Unions are generally considered to be private employee organizations, even if their members may be public employees. A plan sponsored by a private union may be subject to ERISA.


  • ERISA can apply to Individual policies. Many people equate group plans with ERISA and believe individual policies are not subject to ERISA. This is not always true. There are circumstances in which individual insurance policies can be part of an ERISA plan.


Which Key Areas Are Impacted?

Decision Making

When it comes to who is making claim decisions, additional steps are needed to ensure impartiality. Hiring, compensation, termination and promotion of responsible parties must not be based on the likelihood of a claim denial.

Also, vendors selected to handle decisions on the part of the insurer should be monitored closely as courts are now permitting discovery on these relationships. “New regulations require plan fiduciaries to examine vendor agreements to make certain that plan vendors are in compliance with ERISA regulations,” says Magratten.

Denial and Uphold Letters

Communication about the basis of denials - or the upholding of these decisions - should be clear and supported. These letters must include an explanation of the basis for any disagreement with treating physicians and vocational consultants, views of experts retained by the administrator, and SSA determinations. “Letters must include [e]ither the specific internal rules, guidelines, protocols, standards or other similar criteria of the plan relied upon in making the adverse determination or, alternatively, a statement that such rules, guidelines protocols, standards or other similar criteria of the plan do not exist.”

Claimant’s Right to Review and Respond Before Final Uphold

The new regulations may cause analysts to reflect on the need for soliciting reviews. According to Magratten, “Simply because a claimant provides new documentation to a plan does not mean that the plan has been provided with new information. Claim fiduciaries should scrutinize new claim documentation before deciding whether to seek expert review.”

If an administrative review of a claim is conducted and produces new evidence, it must be provided to the claimant “as soon as possible, sufficiently in advance of” the review completion deadline.

Plan Limitations Periods

According to Magratten, “uphold letters must describe any applicable contractual limitations period… including the calendar date on which the contractual limitations period expires for the claim.” He stresses that seeking guidance on the limitations period can be important, especially given variations between states.


The zip code the claimant resides in is a key detail not to overlook. “If they are in a county where 10% or more of the inhabitants are literate only in the same non-English language, then the Administrator must provide information (orally and written) in that particular non-English language.”

Final Thoughts

The new ERISA regulations require several changes to operating procedures, leaving room for questions regarding compliance. SALT Associates and Pierce Atwood have partnered to provide access to free in-person training for Plan fiduciaries and claim staff. To request a training session click here.

The information on this site is available for educational purpose only and does not constitute or contain legal advice. Anything published on this site should not be considered legal opinion or as a substitute for legal counsel. By using this blog site you understand that there is no attorney client relationship between you and the blog/web publisher.