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Watch What You Say: Employee Benefit Claims

Watch What You Say: Employee Benefit Claims
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1 min 46 sec

While the internet has become the primary means of sharing basic employee benefit information, participants often prefer to talk to a plan representative regarding complicated or significant decisions. This person could be from the plan sponsor’s staff or from the plan administrator. A recent Employee Benefits Security Administration (EBSA) letter implies these conversations could impact benefit claims.

Background

Section 503 of ERISA requires that employee benefit plans (e.g., retirement or health and welfare) afford any participant whose claim was denied with a reasonable opportunity to go through a “full and fair review.” The U.S. Department of Labor (DOL) regulations on this issue require that employee benefit plans “establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.” These regulations further require that “a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits.”

The EBSA recently issued an Information Letter (a non-binding written statement that calls attention to established principles under ERISA) stating that the required disclosure of documents and records includes any recordings and/or transcripts of phone calls between the claimant and the fiduciary or administrator, even if the recording was made only for quality-assurance purposes. The EBSA further clarified that a recording made for quality-assurance purposes would also likely make it relevant to the claims process as it demonstrates compliance with administrative processes or safeguards.

This letter, along with the preamble to recent amendments to the relevant regulations, clarifies that plans cannot refuse “video, audio, or other electronic media” as types of evidence if a claim was denied. Plan sponsors and claims administrators should be prepared for these requests and should train personnel handling telephone calls with claimants accordingly.

What You Need to Know

Plan fiduciaries may wish to consider their internal systems for recording calls. Additionally, plan sponsors should review the contractual agreements with their recordkeeper around call center representative accuracy (e.g., descriptions of plan provisions and benefits) and the remediation provisions in the event those conversations are deemed inaccurate or misleading.

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