The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. A benefit is a disability benefit under the regulation, subject to the special rules for disability claim, if the plan conditions its availability to the claimant upon a showing of a disability. If the claims adjudicator must make a determination of disability in order to decide a claim, the claim must be treated as a disability claim for the purposes of the regulation.
If a plan conditions continuation of disability benefit payments on a periodic confirmation of the claimant’s disability and, in conjunction with such a confirmation, determines that the claimant is no longer disabled and, accordingly, terminates payment of benefits, the plan must under the regulations treat as an adverse benefit determination.
An adverse benefit determination includes any denial, reduction, or termination of a benefit. Accordingly, where a plan terminates the payment of disability benefits under such circumstances, the plan is required to provide the claimant a notification of adverse benefit determination and the right to appeal that determination consistent with the regulation. If, on the other hand, a plan provides for the payment of disability benefits for a pre-determined, fixed period (e.g., a specified number of weeks or months or until a specified date), the termination of benefits at the end of the specified period would not constitute an adverse benefit determination under the regulation. Any request by a claimant for payment of disability benefits beyond the specified period, therefore, would constitute a new claim.
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 advise the member 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, the member will have at least 45 days to supply it. The claim then must be decided no later than 30 days after the member supplies 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 the member before the first extension expires. For any additional extensions, the plan needs the members consent. The plan must give notice whether the claim has been denied before the end of the time allotted for the decision.
The claims regulation address two situations in which a plan may have an extension of time for making a disability benefit determination.
1. When a decision cannot be rendered due to any matter beyond the control of the administrator other than the need for additional information from the claimant. In this situation, the extension period is added to the period within which the determination is required to be made. For example, if prior to the end of the initial 45-day period, the administrator determines that, for reasons beyond its control, a decision cannot be rendered, the plan may take up to an additional 30 days (i.e., 30 days in addition to the initial 45-day period). Similarly, if a decision cannot, for similar reasons, be rendered within the initial extension period, the plan may take up to an additional 30 days (i.e., 30 days in addition to the initial 30-day extension period) or up to a total of 105 days to decide the pending claim.
2. When the plan requires additional information from the claimant to make a benefit determination. This situation is governed by the same principles as a pre-service and post-service claim which are: a group health plan may unilaterally extend the decision making on the claims for 15 days after the expiration of the initial period, if the administrator determines that such an extension is necessary for reasons beyond the control of the plan.
If the reason for taking the extension is the failure of the claimant to provide information necessary to decide the claim, and the claimant is so notified of this fact, the time period for making the decision is suspended (tolled) from the date of the notification to the claimant to the earlier of:
- The date on which a response from the claimant is received by the plan
- The date established by the plan for the furnishing of the requested information (at least 45 days)
The extension period (15 days) – within which a decision must be made by the plan – will begin to run from the date on which the claimant’s response is received by the plan (without regard to whether all of the requested information is provided) or, if earlier, the due date established by the plan for furnishing the requested information (at least 45 days).
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.