The DOL has now officially delayed until April 1, 2018 its regulations that amend the claims review and appeal procedures applicable to ERISA-covered employee benefit plans providing disability benefits. Such regulations were originally scheduled to apply to disability benefit claims filed on or after January 1, 2018. We previously commented on the DOL’s proposal to delay these regulations here. The delay gives the DOL time to consider additional comments and data, reassess the impact of the new claims procedures, and revise the regulations as deemed appropriate. Employers should thus expect to receive additional guidance from the DOL before the April 1 effective date. View the final regulations that provide for the delay.
U.S. Department of Labor Proposes Extension of Applicability Date of New Disability Claims Procedures
On October 12, 2017, the DOL issued a proposed rule to delay for 90 days (through April 1, 2018) the applicability of the final regulations which amended the claims procedure requirements for ERISA-covered employee benefit plans that provide disability benefits. The final regulations were issued by the DOL in December 2016 and, as issued, would apply to claims for disability benefits filed on or after January 1, 2018. (Note: a more detailed discussion of the final regulations is available in our prior blog post.) Following the DOL’s issuance of the final regulations, various stakeholders asserted that the final regulations would drive up disability benefit plan costs and cause an increase in litigation and, in doing so, impair workers’ access to disability benefits. The DOL seeks public comments on its proposed 90-day delay of the applicability date of the final regulations in order to solicit additional public input and examine regulatory… Continue Reading
Fifth Circuit Holds Disability Benefit Offset Inappropriate Because of Ambiguous Language in Summary Plan Description
Verizon maintained a long-term disability plan (the “LTD Plan”) insured through MetLife, who had the discretionary authority to interpret the LTD Plan and to adjudicate claims. In 2007, an employee became eligible to receive benefits under both the LTD Plan and a Verizon pension plan due to disability, and the employee elected to take his full pension benefit as a lump sum and then roll it over into an IRA in a direct trustee-to-trustee transfer. The LTD Plan’s summary plan description (the “SPD”) contained language stating that a participant’s long-term disability benefits “may be reduced by other sources of disability income,” including “pension benefits from a Verizon pension plan, if the beneficiary elects to receive them.” MetLife offset the participant’s monthly disability benefit by the amount of the pension benefit he had rolled over into his IRA. The participant appealed countering that because he would not actually receive any of… Continue Reading
An employee wanted to file a claim for disability benefits before his termination of employment, but the employer did not provide him with the necessary paperwork to file a claim under its disability benefits plan for covered employees. This plan was subject to ERISA. After his employment terminated, the former employee submitted claims and appeals for disability benefits, which were denied by the plan’s insurer, Prudential. Prudential determined that the former employee had become disabled after his termination of employment and thus did not have plan coverage at that time. A U.S. District Court in Arizona found this denial of benefits should be reviewed de novo (i.e., without giving deference to the plan administrator’s prior decision to deny benefits) because the plan did not contain an unambiguous grant of discretion to the plan administrator to interpret the terms of the plan and to make final benefit determinations. This discretion was… Continue Reading
A former employee alleged that Aetna, as administrator of FedEx’s short-term disability plan, breached its fiduciary duty under ERISA when Aetna reported to FedEx that the employee filed a disability claim for substance abuse and Aetna later failed to correct this report. FedEx’s drug policy stated that the disability vendor (Aetna) would notify FedEx when an employee sought benefits for substance abuse. The U.S. Court of Appeals for the Tenth Circuit found that compliance with FedEx’s policy could not constitute a breach of fiduciary duty and Aetna had not provided inaccurate information to FedEx and thus the appeals court upheld the district court’s summary judgment on the claim. Williams v. FedEx Corp. Services and Aetna Life Ins. Co., No 16-4032 (10th Cir. Feb. 24, 2017)
Last December, we reported on the DOL’s release of final regulations revising ERISA’s claims procedures for disability benefits. A more in-depth review of the types of benefit plans affected by these final regulations is available on our companion blog, HB Health and Welfare.
Safeguards to Defend Against Conflict of Interest Allegations in the Administration of ERISA Welfare Benefit Claims
In cross-motions for summary judgment in Geiger v. Aetna Life Insurance Company, the U.S. Court of Appeals for the Seventh Circuit considered whether Aetna, the designated claims fiduciary and insurer of disability benefits provided under an employer-sponsored ERISA welfare benefit plan, abused its discretion when it terminated the plaintiff’s disability benefits. The plaintiff was a former employee of the employer-plan sponsor. The terms of the plan specifically granted discretionary authority to Aetna with respect to determining benefits and construing the terms of the plan. However, the plaintiff alleged that Aetna had operated under a conflict of interest, as the party that both determined eligibility for and paid plan benefits, and thus abused its discretion in denying her claim. In deciding that Aetna did not abuse its discretion, the Court considered the following four safeguards that Aetna had undertaken to minimize any conflict of interest: (i) Aetna obtained numerous independent physician… Continue Reading
The U.S. Department of Labor issued final regulations revising the ERISA claims procedures that apply to employee benefit plans offering disability benefits. Generally, these final regulations extend certain procedural rules applicable to claims submitted under group health plans to disability benefit claims submitted under ERISA plans that provide disability benefits. The final regulations apply to claims for disability benefits filed on or after January 1, 2018. View the final regulations here.
On November 18, 2015, the U.S. Department of Labor (“DOL”) published proposed amendments to the claims procedure regulations under ERISA with respect to claims for disability benefits. Generally, these amendments have the effect of extending to disability benefit claims several of the procedural protections that were added by the Affordable Care Act for health benefit claims, particularly regarding internal claims and appeals under group health plans (e.g., providing expanded benefit denial notices written in a culturally and linguistically appropriate manner). If the proposed regulations are adopted as final, administrators of plans providing disability benefits would be required to implement these enhanced claims and appeals procedures. The proposed regulations are available here.
The U.S. Sixth Circuit Court of Appeals recently held that a disability plan participant was not entitled to disgorgement of an insurance company’s profits when the participant had recovered on his wrongful denial of benefits claim. The en banc Sixth Circuit reversed a prior panel’s opinion that held the participant could recover both for the value of unpaid disability benefits plus approximately $3.8 million in profits the insurance company earned on the unpaid amounts. The Sixth Circuit reasoned that equitable relief under ERISA, such as disgorgement of profits, is a “catch all” remedy only available where a participant is not otherwise made whole under another of ERISA’s remedial provisions. Here, the participant had been made whole by recovering the unpaid disability benefits plus his attorneys’ fees. Accordingly, to permit him to also recover the insurance company’s profits would result in a double recovery. The Sixth Circuit’s en banc opinion can… Continue Reading