Claims Procedure Requirements for ERISA Benefit Plans

Summary

This practice note covers the standards established by the Department of Labor (DOL) pursuant to the Employee Retirement Income Security Act (ERISA) that must be met to ensure that an ERISA-governed benefit plan has a process reasonably designed to provide participants and beneficiaries with a full and fair review of benefit claims and claimant appeals of adverse benefit determinations. These rules apply to all types of ERISA plans—including retirement, health and welfare, fringe benefit, and other plans, although there are distinctions for group health plan claims and claims for benefits arising from a plan's determination of disability. This practice note also describes additional rules imposed by the Patient Protection and Affordable Care Act (ACA) applicable to most group health plans.