What are the Department of Labor's Regulations?
Insurance companies processing claims under ERISA must comply with U.S. Department of Labor regulations. They are easily available at The U.S. Department of Labor Web site.
Some of the important provisions in these regulations are:
- That the insurance company must maintain reasonable claims procedures and provide written claim determinations within a specified time period. 29 CFR 2560.503.1(f);
- That the insurance company must provide a detailed written explanation for the basis of any denial and afford the insured the right to appeal the denial and have a full and fair review of the claim and adverse benefit decision. 29 CFR 2560.503.1(g)-(j);
- That the denial shall state the specific reason for the denial, including reference to the specific policy provision(s) and a description of any additional material or information necessary to perfect the claim. 29 CFR 2560.503.1(g)(1)(ii),(iii);
- That the insurance company shall provide a description of or a copy of any internal rule, guideline, protocol, or other similar criterion that was relied upon in arriving at the denial. 29 CFR 2560.503.1(g)(1)(v)(A);
- Upon request, a policyholder may obtain the entire file relating to the claim free of charge. 29 CFR 2560.503.1(h)(2)(i); 29 CFR 2560.503.1(j)(3);
Please contact us if you have further questions about ERISA litigation.