Department of Labor implements disability income claim rules

Effective April 1, 2018, employee benefit plans must comply with new rules under the Employee Retirement Income Security Act (ERISA), implemented by the U.S. Department of Labor. These rules give workers new procedural protections for claims administered under plans offering disability income benefits by requiring increased communications between the employee and the claim administrator when a claim or appeal is being denied. 

UnitedHealthcare is aware of these ERISA updates and has implemented necessary changes relative to its administration of short-term and long-term disability claims as well as life waiver of premium claims filed on the basis of total disability. 

Existing ERISA rules require that disability claimants receive a clear explanation of why their claim was denied and their rights to appeal that denial. Under the new rule, the claimant must also be provided with the following information at the claim denial and appeal level:

  • A more detailed explanation of the adverse benefit decision,

  • Copies of any internal rules or guidelines that were relied upon in making that determination,

  • A statement that the claimant is entitled to receive, upon request, copies of the claim file materials that were relevant to the benefit determination, and

  • A culturally and linguistically appropriate notice that offers information on translation services, if necessary. 

In the event an adverse determination is likely going to be made on appeal and that decision will be made based on new evidence and/or a new rationale, the claimant must be provided with this information first and given the opportunity to respond before the appeal decision is finalized. 

These changes primarily relate to the administration of disability income claims; therefore, no changes to the Certificate of Coverage or the Summary Plan Description are needed. The Statement of Employee ERISA Rights, which is sent with the Certificate of Coverage upon request, has been updated to include the new provisions. 

Note: These new regulations do not change the medical claims appeals process as outlined under the Affordable Care Act.

For questions, please contact your UnitedHealthcare representative.