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Employee Benefits Security Administration

Fact Sheet

Claims Procedure Regulation

EBSA plans to update and clarify the claims procedure requirements to enhance retirement and health benefit security and to protect workers rights and benefits, ultimately supporting the Secretary's good jobs for everyone policy.

Key Action: Proposed Regulation

The Department's EBSA plans to publish a proposed regulation in April 2011 that will amend the current claims procedure regulation and enhance the claims review process.

Key Concern and Issues to be Addressed

Due to the significance of the rules that govern the filing and review of 1.4 billion health, disability, and pension claims and 531,000 appeals annually, the Department will review the adequacy of the notice and timing and other requirements of the claims procedure regulation and propose changes necessary to ensure that workers receive timely, complete and understandable explanations of benefit claim denials, as well as a full and fair review of any denied claims when a claim determination is appealed to a plan fiduciary. This initiative also will update the claims procedure rules to comport with the requirements of the recently enacted Patient Protection and Affordable Care Act of 2010.

Background

Section 503(2) of the Employee Retirement Income Security Act requires that participants be provided a full and fair review of claims. The Department published the current claims procedure regulation on November 21, 2000. After almost 10 years of experience in implementing the current regulation, the Department believes there is a need to review the extent to which the claims procedure regulation is working, given its impact on the retirement and health benefit security and benefit determinations of so many Americans.

There are an estimated 2.8 million health plans covering 138 million participants and beneficiaries and 708,000 pension plans covering 124 million participants and beneficiaries subject to the current claims procedure regulation.