ERISA Claims Procedure and Benefit Disputes
The Claims Regulation
ERISA section 503 and the DOL claims procedure regulation establish minimum standards for handling benefit claims and appeals. Group health plans and disability plans follow stricter timelines than pension plans. The regulation requires a full and fair review, disclosure of the basis for denial, and an opportunity to submit evidence.
Timelines
For group health claims, urgent care claims require a decision within 72 hours, pre-service claims within 15 days, and post-service claims within 30 days. Appeals have shorter timelines. Disability claims generally require a decision within 45 days, with extensions. Pension claims generally require a decision within 90 days, extendable.
Standard of Review
Courts generally review benefit denials under an abuse of discretion standard when the plan grants discretionary authority, and de novo otherwise. The claims record is typically limited to the administrative record.
Traps to Watch
- Confusing the initial claim deadline with the appeal deadline.
- Assuming all plans have the same timelines; health and disability plans have stricter rules.
- Missing that a failure to follow claims procedures can result in deemed exhaustion or a remand.
- Overlooking the requirement to provide documents upon request.
Rule of Thumb
Identify the type of claim first (urgent, pre-service, post-service, disability, pension), then apply that timeline. Most exam errors come from using the pension timeline for a health claim.