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DOL's New Rules on ERISA Claims Procedure for Disability Benefits
The Department of Labor (DOL) issued regulations that revise the ERISA claims procedure regulations for employee benefit plans that provide disability benefits (the New Disability Claims Regulations). They are based on the Affordable Care Act's (the ACA) enhanced claims and appeals regulations for group health plans (the ACA Enhanced Regulations). The scope of the New Regulations are broader than you may realize and apply to any plan, regardless of how it is characterized, that provides benefits or rights that are contingent on whether the plan determines an individual to be disabled. This can include ERISA-governed short-term disability plans, long-term disability plans, qualified retirement plans (e.g., a 401(k) plan), nonqualified retirement plans, workman's compensation and health, wellness and welfare plans. Importantly, the New Disability Claims Regulations would not apply if a plan does not make the determination of disability, but instead relies on a third party's determination of disability, such as a determination of disability made by the Social Security Administration.
Plans Subject to the Final Rule
The final rule applies to plans (either welfare or retirement) where the plan conditions the availability of disability benefits to the claimant upon a showing of disability. For example, if a claims adjudicator must make a determination of disability in order to decide a claim, the plan is subject to the final rule. Generally, this would include benefits under a long-term disability plan a short-term disability plan or a workman's compensation plan to the extent that it is governed by ERISA. However, the following short-term disability benefits are not subject to ERISA and, therefore, are not subject to the final rule:
- Short-term disability benefits they are paid pursuant to an employer's payroll practices (e., paid out of the employer's general assets on a self-insured basis with no employee contributions); and
- Short-term disability benefits that are paid pursuant to an insurance policy maintained solely to comply with a state-mandated disability law (for example, in California, New Jersey, New York, and Rhode Island).
In addition, if benefits are conditioned on a finding of a disability made by a third party other than the plan itself (such as the Social Security Administration or insurer/third-party administrator of the employer's long-term disability plan), then a claim for such benefits is not treated as a disability claim and is also not subject to the final rule. For example, if a retirement plan's determination of disability is conditioned on the determination of disability under the plan sponsor's long-term disability plan, then the retirement plan is not subject to the final rule (but the final rule would apply to the underlying long-term disability plan).
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