FILING A CLAIM

FOR YOUR

HEALTH OR DISABILITY

BENEFITS

U.S. Department of Labor

Employee Benefits Security Administration
This publication has been developed

by the U.S. Department of Labor,

Employee Benefits Security Administration,

and is available on the Web at

www.dol.gov/ebsa.

For a complete list of the agency’s

publications, call our toll free number at

1-866-444-EBSA (3272)

This material will be made available

in alternate format upon request:

Voice phone: 202-693-8664 TTY: 202-501-3911

Printed September 2006

This booklet constitutes a small entity compliance guide for purposes of the Small Business

Regulatory Enforcement Act of 1996.

INTRODUCTION

f you participate in a health plan or a plan that

provides disability benefits, you will want to know

how to file a claim for your benefits. The steps

outlined below describe some of your plan’s

obligations and briefly explain the procedures and

timelines for filing a health or disability benefits

claim.

Before you file, however, be aware of the

Employee Income Retirement Security Act of 1974

(ERISA), a law that protects your health and disability

benefits and sets standards for those who administer

your plan. Among other things, the law and rules

issued by the Department of Labor include

requirements for the processing of benefit claims,

the timeline for a decision when you file a claim, and

your rights when a claim is denied.

You should know that ERISA does not cover

some employee benefit plans (such as those

sponsored by government entities and most

churches). If, however, you are one of the millions of

participants and beneficiaries who depend on health

or disability benefits from a private-sector

employment-based plan, take a few minutes and

read on to learn more.
Reviewing

The Summary Plan

Description

A key document related to your plan is the

summary plan description (SPD). The SPD

provides a detailed overview of the plan–how it

works, what benefits it provides, and how to file

a claim for benefits. It also describes your rights

as well as your responsibilities under ERISA and your plan. For some singleemployer collectively bargained plans, you should also check the collective

bargaining agreement’s claim filing, grievance, and appeal procedures as they

may apply to claims for health and disability benefits.

Before you apply for health or disability benefits, review the SPD to

make sure you meet the plan’s requirements and understand the procedures

for filing a claim. Sometimes claims procedures are contained in a separate

booklet that is handed out with your SPD. If you do not have a copy of your

plan’s SPD or claims procedures, make a written request for one or both to

your plan’s administrator. Your plan administrator is required to provide

you with a copy.

Filing A Claim

An important first step is to check your SPD to

make sure you meet your plan’s requirements to

receive benefits. Your plan might say, for

example, that a waiting period must pass before

you can enroll and receive benefits or that a

dependent is not covered after a certain age.

Also, be aware of what your plan requires to file

a claim. The SPD or claims procedure booklet

must include information on where to file, what to file, and whom to

contact if you have questions about your plan, such as the process for

providing a required pre-approval for health benefits. Plans cannot charge

any filing fees or costs for filing claims and appeals.

If, for any reason, that information is not in the SPD or claims

procedure booklet, write your plan administrator, your employer’s human

resource department (or the office that normally handles claims), or your

employer to notify them that you have a claim. Keep a copy of the letter for

your records. You may also want to send the letter by certified mail, return

receipt requested, so you will have a record that the letter was received

and by whom.

If it is not you, but an authorized representative who is filing the

claim, that person should refer to the SPD and follow your plan’s claims

procedure. Your plan may require you to complete a form to name the

representative. If it is an emergency situation, the treating physician can

automatically become your authorized representative without you having

to complete a form.

When a claim is filed, be sure to keep a copy for your records.

2 3 U.S. Department of Labor Employee Benefits Security Administration

FILING A CLAIM FOR YOUR HEALTH OR DISABILITY BENEFITS

 Plans cannot

 charge any filing fees

 or costs for filing

claims and appeals.

 Plans cannot

 charge any filing fees

 or costs for filing

claims and appeals.
Types Of Claims

All health and disability benefit claims must be

decided within a specific time limit, depending

on the type of claim filed.

Group health claims are divided into three

types: urgent care, pre-service and post-service

claims, with the type of claim determining how

quickly a decision must be made. The plan

must decide what type of claim it is except

when a physician determines that the urgent care is needed.

Urgent care claims are a special kind of pre-service claim that requires a

quicker decision because your health would be threatened if the plan took

the normal time permitted to decide a pre-service claim. If a physician with

knowledge of your medical condition tells the plan that a pre-service claim is

urgent, the plan must treat it as an urgent care claim.

Pre-service claims are requests for approval that the plan requires you to

obtain before you get medical care, such as preauthorization or a decision on

whether a treatment or procedure is medically necessary.

Post-service claims are all other claims for benefits under your group health

plan, including claims after medical services have been provided, such as

requests for reimbursement or payment of the costs of the services provided.

Most claims for group health benefits are post-service claims.

Disability claims are requests for benefits where the plan must make a

determination of disability to decide the claim.

Waiting For

A Decision On

Your Claim

As noted, ERISA sets specific periods of

time for plans to evaluate your claim and

inform you of the decision. The time limits

are counted in calendar days, so weekends

and holidays are included. These limits do

not govern when the benefits must be paid or provided. If you are entitled

to benefits, check your SPD for how and when benefits are paid. Plans are

required to pay or provide benefits within a reasonable time after a claim is

approved.

Urgent care claims must be decided as soon as possible, taking into

account the medical needs of the patient, but no later than 72 hours after

the plan receives the claim. The plan must tell you within 24 hours if more

information is needed; you will have no less than 48 hours to respond.

Then the plan must decide the claim within 48 hours after the missing

information is supplied or the time to supply it has elapsed. The plan

cannot extend the time to make the initial decision without your consent.

The plan must give you notice that your claim has been granted or denied

before the end of the time allotted for the decision. The plan can notify you

orally of the benefit determination so long as a written notification is

furnished to you no later than three days after the oral notification.

Pre-service claims must be decided within a reasonable period of time

appropriate to the medical circumstances, but no later than 15 days after

the plan has received the claim. The plan may extend the time period up

to an additional 15 days if, for reasons beyond the plan’s control, the

decision cannot be made within the first 15 days. The plan administrator

4 5 U.S. Department of Labor Employee Benefits Security Administration

FILING A CLAIM FOR YOUR HEALTH OR DISABILITY BENEFITS
must notify you prior to the expiration of the first 15-day period, explaining

the reason for the delay, requesting any additional information, and advising

you when the plan expects to make the decision. If more information is

requested, you have at least 45 days to supply it. The plan then must decide

the claim no later than 15 days after you supply the additional information or

after the period of time allowed to supply it ends, whichever comes first. If

the plan wants more time, the plan needs your consent. The plan must give

you written notice that your claim has been granted or denied before the end

of the time allotted for the decision.

Post-service health claims must be decided within a reasonable period of

time, but not later than 30 days after the plan has received the claim. If,

because of reasons beyond the plan’s control, more time is needed to review

your request, the plan may extend the time period up to an additional 15days.

However, the plan administrator has to let you know before the end of the

first 30-day period, explaining the reason for the delay, requesting any

additional information needed, and advising you when a final decision is

expected. If more information is requested, you have at least 45 days to

supply it. The claim then must be decided no later than 15 days after you

supply the additional information or the period of time given by the plan to do

so ends, whichever comes first. The plan needs your consent if it wants more

time after its first extension. The plan must give you notice that your claim

has been denied in whole or in part (paying less than 100% of the claim)

before the end of the time allotted for the decision.

Disability claims must be decided within a reasonable period of time, but

not later than 45 days after the plan has received the claim. If, because of

reasons beyond the plan’s control, more time is needed to review your

request, the plan can extend the timeframe up to 30 days. The plan must tell

you prior to the end of the first 45-day period that additional time is needed,

explaining why, any unresolved issues and additional information needed,

and when the plan expects to render a final decision. If more information is

requested during either extension period, you will have at least 45 days to

supply it. The claim then must be decided no later than 30 days after you

supply the additional information or the period of time given by the plan to

do so ends, whichever comes first. The plan administrator may extend the

time period for up to another 30 days as long as it notifies you before the

first extension expires. For any additional extensions, the plan needs your

consent. The plan must give you notice when your claim has been denied

before the end of the time allotted for the decision.

If your claim is denied, the plan administrator must send you a

notice, either in writing or electronically, with a detailed explanation of

why your claim was denied and a description of the appeal process. In

addition, the plan must include the plan rules, guidelines, or exclusions

(such as medical necessity or experimental treatment exclusions) used in

the decision or provide you with instructions on how you can request a

copy from the plan. The notice may also include a specific request for you

to provide the plan with additional information in case you wish to appeal

your denial.

6 7 U.S. Department of Labor Employee Benefits Security Administration

FILING A CLAIM FOR YOUR HEALTH OR DISABILITY BENEFITS

 If your claim is

 denied, the plan must

 give you notice with a

 detailed explanation

 and a description of

the appeal process.

 If your claim is

 denied, the plan must

 give you notice with a

 detailed explanation

 and a description of

the appeal process.
Appealing

A Denied Claim

Claims are denied for various reasons. Perhaps

the services you received are not covered by

your plan. Or, perhaps the plan simply needs

more information about your claim. Whatever

the reason, you have at least 180 days to file an

appeal (check your SPD or claims procedure to

see if your plan provides a longer period).

Use the information in your claim denial notice in preparing your

appeal. You should also be aware that the plan must provide claimants, on

request and free of charge, copies of documents, records, and other

information relevant to the claim for benefits. The plan also must identify, on

your request, any medical or vocational expert whose advice was obtained by

the plan. Be sure to include in your appeal all information related to your

claim, particularly any additional information or evidence that you want the

plan to consider, and get it to the person specified in the denial notice before

the end of the 180-day period.

Reviewing An

Appeal

On appeal, your claim must be reviewed by

someone new who looks at all of the information

submitted and consults with qualified medical

professionals if a medical judgment is involved.

This reviewer can not be a subordinate of the

person who made the initial decision and must

give no consideration to that decision.

Plans have specific periods of time within which to review your

appeal, depending on the type of claim.

Urgent care claims must be reviewed as soon as possible, taking into

account the medical needs of the patient, but not later than 72 hours after

the plan receives your request to review a denied claim.

Pre-service claims must be reviewed within a reasonable period of time

appropriate to the medical circumstances, but not later than 30 days after

the plan receives your request to review a denied claim.

Post-service claims must be reviewed within a reasonable period of time,

but not later than 60 days after the plan receives your request to review a

denied claim.

If a group health plan needs more time, the plan must get your

consent. If you do not agree to more time, the plan must complete the

review within the permitted time limit.

Disability claims must be reviewed within a reasonable period of time,

but not later than 45 days after the plan receives your request to review a

denied claim. If the plan determines special circumstances exist and an

extension is needed, the plan may take up to an additional 45 days to

decide the appeal. However, before taking the extension, the plan must

notify you in writing during the first 45-day period explaining the special

circumstances, and the date by which the plan expects to make

the decision.

There are two exceptions to these time limits. In general, singleemployer collectively bargained plans may use a collectively bargained

grievance process for their claims appeal procedure if it has provisions on

filing, determination and review of benefit claims. Multi-employer

collectively bargained plans are given special timeframes to allow them to

schedule reviews on appeal of post-service claims and disability claims for

the regular quarterly meetings of their board of trustees. If you are a

participant in one of those plans and you have questions about your plan’s

procedures, you can consult your plan’s SPD and collective bargaining

agreement or contact the Department of Labor’s Employee Benefits

Security Administration (EBSA) at the phone number below.

Plans can require you to go through two levels of review of a

denied health or disability claim to finish the plan’s claims process. If two

levels of review are required, the maximum time for each review generally

8 9 U.S. Department of Labor Employee Benefits Security Administration

FILING A CLAIM FOR YOUR HEALTH OR DISABILITY BENEFITS
is half of the time limit permitted for one review. For example, in the case of

a group health plan with one appeal level, as noted above, the review of a preservice claim must be completed within a reasonable period of time

appropriate to the medical circumstances but no later than 30 days after the

plan gets your appeal. If the plan requires two appeals, each review must be

completed within 15 days for pre-service claims. If your claim on appeal is

still denied after the first review, the plan has to allow you a reasonable

period of time (but not a full 180 days) to file for the second review.

Once the final decision on your claim is made, the plan must send

you a written explanation of the decision. The notice must be in plain

language that can be understood by participants in the plan. It must include

all the specific reasons for the denial of your claim on appeal, refer you to the

plan provisions on which the decision is based, tell you if the plan has any

additional voluntary levels of appeal, explain your right to receive documents

that are relevant to your benefit claim free of charge, and describe your rights

to seek judicial review of the plan’s decision.

If Your Appeal

Is Denied

If the plan’s final decision denies your claim, you

may want to seek legal advice regarding your

rights to bring an action in court to challenge

the denial. Normally, you must complete your

plan’s claim process before filing an action in

court to challenge the denial of a claim for

benefits. However, if you believe your plan

failed to establish or follow a claims procedures consistent with the

Department’s rules described in this booklet, you may want to seek legal

advice regarding your right to ask a court to review your benefit claim

without waiting for a decision from the plan. You also may want to contact the

nearest EBSA office about your rights if you believe the plan failed to follow

any of ERISA’s requirements in handling your benefit claim.

Filing A Claim–

Summary

–Check your plan’s benefits and claims

procedure before filing a claim. Read

your SPD and contact your plan

administrator if you have questions.

–Once your claim is filed, the maximum

allowable waiting period for a decision

varies by the type of claim, ranging from 72 hours to 45 days.

However, your plan can extend certain time periods but must notify

you before doing so. Usually, you will receive a decision within this

timeframe.

–If your claim is denied, you must receive a written notice, including

specific information about why your claim was denied and how to file

an appeal.

10 11 U.S. Department of Labor Employee Benefits Security Administration

FILING A CLAIM FOR YOUR HEALTH OR DISABILITY BENEFITS

 Read your SPD

 and contact your plan

 administrator if you

 have questions.

 Read your SPD

 and contact your plan

 administrator if you

 have questions.
–You have at least 180 days to request a full and fair review of your

denied claim. Use your plan’s appeals procedure and be aware that

you may need to gather and submit new evidence or information to help

the plan in reviewing the claim.

–Reviewing your appeal can take between 72 hours and 60 days

depending on the type of claim. The law and the Department’s rules

allow a disability plan additional time if the plan’s administrator has

notified you beforehand of the need for an extension. For an appeal of a

health claim, the plan needs your permission for an extension. The

plan must send you a written notice, telling you whether the appeal was

granted or denied.

–If the appeal is denied, the written notice must tell you the reason it

was denied, describe any additional appeal levels or voluntary appeal

procedures offered by the plan, and contain a statement regarding your

rights to seek judicial review of the plan’s decision.

–You may decide to seek legal advice if your claim’s appeal is denied

or if the plan failed to establish or follow reasonable claims procedures.

If you believe the plan failed to follow ERISA’s requirements, you also

may want to contact the nearest EBSA office concerning your rights

under ERISA.

12 13 U.S. Department of Labor Employee Benefits Security Administration

Resources

For the EBSA regional office nearest

you or a copy of any EBSA publications

call toll free:

1-866-444-EBSA (3272)

Or visit EBSA’s Web site at:

www.dol.gov/ebsa

FILING A CLAIM FOR YOUR HEALTH OR DISABILITY BENEFITS

 When a claim

 is filed, be sure to keep

 a copy for your

records.