ERISA-An Additional Thought On The New Claims Procedure Requirements For Disability Claims

Further, to yesterdays’ blog, the DOL had issued earlier FAQs (in December 2012) pertaining to the ERISA claims procedure regulations.  The earlier FAQs are here.  They make one interesting suggestion, that would appear to apply to the prior and new provisions in those regulations relating to disability claims. The earlier FAQs indicate that, when the plan determines whether a participant is disabled, and thus entitled to disability benefits, based on a determination of disability made by a third party (not the plan), then the following obtains: a claim for disability benefits, filed by a participant, is treated as any other claim for pension benefits, and the prior and rules in the claims procedure regulations pertaining to disability claims do not apply.

More specifically, the earlier FAQs say the following, in Q-A9:

“However, if a plan provides a benefit the availability of which is conditioned on a finding of disability, and that finding is made by a party other than the plan for purposes other than making a benefit determination under the plan, then the special rules for disability claims need not be applied to a claim for such benefits.  For example, if a pension plan provides that pension benefits shall be paid to a person who has been determined to be disabled by the Social Security Administration or under the employer’s long-term disability plan, a claim for pension benefits based on the prior determination that the claimant is disabled would be subject to the regulation’s procedural rules for pension claims, not disability claims.”

Thus, if a plan treats a participant as being disabled, based on being granted an award of a Social Security disability benefit, the plan’s claims procedures would not have to reflect or apply the prior or new rules in the regulations that apply to disability claims.  The caution is that the plan would have to base its determination of disability solely on the grant of the award.  If the plan retains any other requirement for treating a participant as being disabled, such as the plan administrator retaining any authority to challenge and deny such treatment despite the grant of a Social Security disability award, then the plan would have to handle a participant’s claim for a disability benefit wholly or partly in accordance with the (prior and new) rules in the regulations relating to disability claims.


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