De Novo Review for Non-Compliance with Claims-Procedure Rule

June 30, 2016

An ERISA plan’s failure to comply with the DOL’s claims-procedure regulations resulted in the 2nd Circuit reviewing the claim de novo. De novo review means that the court provided the plan with no deference towards its decision to deny the claim. The Court held that de novo review was appropriate unless the plan had otherwise established procedures in full conformity with the regulations and showed that the failure to comply with the regulations was inadvertent and harmless. Plan Administrators want their decision to deny a claim to be given deference by the courts. As a result, Plan Administrators should go through and make sure that their plans are in full compliance with the DOL claims-procedure regulations. Among other things, the rules require that a notification of a final adverse benefit determination must provide the specific reason for the denial, reference the plan provisions on which the determination was based and provide a description of the plan’s review procedures and applicable time limits, including a statement regarding the participant’s right to bring action under section 502 of ERISA.

 

Halo v. Yale Health Plan, No. 14-4005 (2d Cir. Apr. 12, 2016)

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