Obama Administration Telling Companies They Must Explain How Workers Can Appeal Benefits Claims That Are Denied
The Obama administration is planning to upgrade consumer protections for tens of millions of workers and family members covered by health, disability and pension plans, ordering companies to clearly explain decisions on claims and how employees can dispute denials.
The basic idea is to require health and other plans to spell out what a worker needs to know to safeguard his rights.
"People need to have a clear roadmap to appeal claims," Phyllis Borzi, assistant secretary for employee benefits at the Labor Department, said in an interview.
Department officials also want to make the appeals process more responsive. One of the changes under consideration would require health plans to decide appeals for urgent medical care in 24 hours, instead of up to 72 hours as currently allowed.
"On the health side, this is significant because a lot of people have experienced a situation where a claim is denied," said Paul Fronstin, a policy expert for the nonpartisan Employee Benefit Research Institute. "Now there would be an expedited process to address that."
Officials say they plan to issue the new rules by the spring of next year.
The health, disability and retirement plans at issue fall under the umbrella of a 1970s federal law called the Employee Retirement Income Security Act, which gives employers flexibility to design benefit programs while setting basic standards.
About 130 million people are covered by health plans governed by the law, including most employees of major companies.
This year's health care overhaul included a "patient's bill of rights" that added new appeals protections for people in private insurance plans. But many employees at big companies did not benefit from those improvements. That's because they are in plans considered "grandfathered" and outside the scope of the overhaul legislation.
However, those same health plans do fall within the jurisdiction of the 1970s law and the regulations the Labor Department is now reviewing.
Officials said they had planned to update the regulations all along. The health care law "isn't the end of the story," said Borzi.
On some details, the reach of the new regulations would actuallly be broader than President Barack Obama's signature health care law. That's because the rules would also apply to retirement and disability insurance plans.
About 50 million people working for private employers are covered by retirement plans, including traditional pensions and 401(k) plans. Disability insurance plans cover tens of millions more.
"Nothing in the (health care) act addressed changes for disability and pension plans," said Borzi. "What we hope is that ... it will be the addition of important protections."
One problem that can create confusion for employees is that the rules for dealing with disputes can vary widely, depending on the type of benefit that's involved.
For example, employees have 180 days to appeal a health plan's decision to deny a claim for medical benefit. But for a dispute over a pension claim, the timeline is shorter -- only 60 days.
"Time is not always on your side," said Rebecca Davis, a lawyer for the Pension Rights Center, a consumer advocacy group. Pensions are "a complicated area, and the way the law is written, it kind of expects individuals to do these appeals on their own."
An employee might have to go to considerable lengths to contest an unfavorable decision on a pension. That could include compiling a documented work history, or even finding a specialized lawyer. Davis said her group is asking the Labor Department to allow the same length of time for pension appeals as is permitted for disputes involving health care.
"We're asking them specifically to revisit the pension claims procedure ... to make it more equitable for participants," she said.
It's unclear how the department will rule on the issue.