With the Patient Protection and Affordable Care Act, we have added an extra component of the appeals process to include an external review. While this is added for health plans, other welfare plans like disability or life, and of course retirement plans, do not have this same requirement. But what happens if, during the course of the appeals process, the plan administrator comes across information that might impact the decision on appeal that makes the administrator want to grant the appeal? Does the administrator have to disclose why?
First, we can operate on the presumption that there would not be an appeal unless the participant was being denied a benefit (or at least seeking to modify a benefit granted). The initial "internal" appeal requires the administrator to consider whatever additional information the participant chooses to provide. Plus, the administrator has to provide to the participant that information it relied on in denying the claim. But the administrator may also get information from someone other than the participant during the appeal. So how does this impact the appeals process?
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