Claims Procedure ERISA Requirements Checklist (Disability Benefits)

Summary

This checklist describes the enhanced standards for a benefit plan's internal claims procedure for benefits conditioned on a determination of disability under the Employee Retirement Income Security Act (ERISA). The generally applicable ERISA rules require plans covered by Title I of ERISA (see ERISA Coverage of Benefit Plans) to establish and maintain a process reasonably designed to ensure a full and fair review of benefit claims and claimant appeals of adverse determinations. Those rules are augmented, as described here, for disability claims. This checklist identifies and describes the 2016 enhancements to the disability claim rules adopted by the Department of Labor (DOL) in 2016, which apply for claims filed after April 1, 2018. See 81 Fed. Reg. 92,316 (Dec. 19, 2016); 82 Fed. Reg. 56,560 (Nov. 29, 2017). The enhancements are modeled on requirements made applicable to group health plans under the Patient Protection and Affordable Care Act (ACA).