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Benefit Plans Should Send Notices to Claimants' Reps: EBSA

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An arm of the U.S. Department of Labor has given a boost to organizations that help benefit plan enrollees resolve claim disputes.

The department’s Employee Benefits Security Administration (EBSA) told a lawyer earlier this week that past department guidance requires plans to send notices about claims and related matters to claimants’ authorized representatives.

(Related: DOL Blocks State Benefit Plan Payment Rules)

Elizabeth Goodman, an official at EBSA’s Office of Regulations and Interpretations, wrote in an information letter that a plan can establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant.

“The procedure cannot prevent claimants from choosing for themselves who will act as their representative or preclude them from designating an authorized representative for the initial claim, an appeal of an adverse benefit determination, or both,” Goodman wrote in the letter.

A plan must describe the procedures for designating an authorized representative in the plan’s claim procedures, and in the plan’s summary plan description, or another document that comes with the summary plan description, Goodman wrote.

Goodman addressed the letter to Jonathan Sistare, a lawyer in Dublin, New Hampshire.

Sistare was writing on behalf of The Justus Group L3C, an organization that helps consumers with filing health insurance claims and claim denial appeals.


A copy of the new EBSA information letter is available here.

— Read Plans Reject 19% of In-Network Claims: Kaiseron ThinkAdvisor.

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