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Best Practices in Administering Benefit Claims #6 – Distinguishing an Inquiry from a Claim

It’s Week #6, and we have turned the corner in our Top 10 Best Practices in Administering Benefit Claims.  In case you missed any (or all) of the first five best practices, links to each of them appear below.  This week we discuss how to distinguish an inquiry from a claim for benefits.

The claims and appeals procedures only apply insofar as there has been a “claim for benefits” under the plan.  In general, a “claim for benefits” is a request for benefits made by a claimant in accordance with the plan’s reasonable procedures for filing such claims.  Ideally, a participant or beneficiary would specify in their communications that s/he is making a “claim for benefits” or otherwise asserting that s/he is entitled to some benefits under the plan.  Unfortunately, participants and beneficiaries (and even their authorized representatives) are often less than clear about what it is they are seeking.

The U.S. Department of Labor is of the view that mere casual inquiries about benefits or when benefits might be paid do not qualify as formal “claims for benefits.”  Similarly, an individual’s question concerning his/her eligibility for coverage and the administrator’s subsequent eligibility determination is not subject to the claims and appeals procedures.  On the other hand, if an individual files a claim for benefits and the administrator denies that claim on the basis of ineligibility, then the claims and appeals procedures are triggered even though the denial is based on an eligibility issue.

Careful consideration should be given to whether a participant’s (or beneficiary’s) communication triggers the plan’s claims process.  For instance, does the plan require claims to be in writing, or are telephonic claims accepted?  Has the participant or beneficiary submitted all required documentation with the claim?  Should an inquiry, although not technically a claim, be processed through the plan’s claims procedures?  When is it appropriate to do so?  Are there strategic reasons to do so in the particular situation?  There is no one-size-fits-all answer to many of these considerations and each inquiry and claim should be evaluated on its own facts, while ensuring that there is consistency in the way inquiries and claims are managed.

In our next best practice, we’ll discuss the “fiduciary exception” to the attorney-client privilege.

You can find our previously published best practices here:

© 2019 Proskauer Rose LLP.

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About this Author

Paul Hamburger Employee Benefits Law Attorney Proskauer Rose Law Firm
Partner

Paul M. Hamburger is co-chair of the Employee Benefits & Executive Compensation Group and head of the Washington, DC office. Paul is also a leader of the Practice Center’s health and welfare subgroup and a member of Proskauer’s Health Care Reform Task Force.

Paul provides technical knowledge and advice to employers on all aspects of their employee benefit programs, and advises employee benefit plan trustees and service providers on ERISA and employee benefit plan-related matters. He has extensive experience in negotiating service provider...

202.416.5850
Russell L Hirschhorn ERISA Litigation, employee benefits attorney, Proskauer
Senior Counsel

Russell Hirschhorn is a Senior Counsel in the Labor & Employment Law Department, where he focuses on complex ERISA litigation and advises employers, fiduciaries and trustees on ERISA benefit and fiduciary issues. 

Russell represents employers, plan sponsors, plans, trustees, directed trustees and fiduciaries in all phases of litigation, arbitration and mediation involving employee benefits, including class action and individual claims relating to ERISA’s fiduciary duty and prohibited transaction provisions, denials of claims for benefits, severance plans, ERISA Section 510, retiree benefits, ERISA preemption of state law claims, plan investment losses, cash balance plan conversions, plan amendments or terminations, withdrawal liability, and employer contributions to multiemployer funds

212.969.3286
Malerie Bulot Labor Employment Attorney
Associate

Malerie L. Bulot is an associate in the Labor & Employment Law Department and a member of the Employee Benefits & Executive Compensation Group. Malerie received her J.D. and diploma in comparative law, magna cum laude, from Louisiana State University Paul M. Hebert Law Center, where she was a senior editor of the Louisiana Law Review and Order of the Coif. While at LSU, she served as a judicial extern to United States District Judge Shelly D. Dick, Middle District of Louisiana.

Education

  • Louisiana State University Paul M. Hebert Law Center , J.D., D.C....
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