Additional appeals

AuthorScott M. Riemer/Jennifer L. Hess
Chapter 9
You just worked many hours to provide the best appeal possible for
your client. Despite your best eorts, the insurer denies the appeal. Can
you now bring a lawsuit against the insurer on your client’s behalf? Most
likely yes, but maybe no.
e Department of Labor Regulations permit disability benet plans
to require a claimant to exhaust up to two appeals of an adverse benet
determination before bringing a civil action. See 29 C.F.R. §2560.503-1(c)
(2). Despite this, few if any disability insurers require that a claimant
submit more than one appeal. Many insurers, however, oer claimants
the opportunity to do a second voluntary appeal pursuant to 29 C.F.R.
§2560.503-1(c)(3), which provides as follows:
To the extent that a plan oers voluntary levels of appeal (except
to the extent that the plan is required to do so by State law),
including voluntary arbitration or any other form of dispute
resolution, in addition to those permitted by paragraph (c)(2)
of this section, the claims procedures provide that:
(i) e plan waives any right to assert that a claimant has
failed to exhaust administrative remedies because the
claimant did not elect to submit a benet dispute to any
such voluntary level of appeal provided by the plan;
(ii) e plan agrees that any statute of limitations or other
defense based on timeliness is tolled during the time that
any such voluntary appeal is pending;

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