What are the ABC's of administrative review? When commencing administrative review/appeal of a rejected claim for life insurance benefits per an employee benefit plan, what is the usual process? How is the record submitted for review and what party determines what the record to be reviewed contains? What does the record normally contain? What access does the claimant have to evidence and/or documents in the record? Can claimant call attention to or request review of certain speicifc items in the record?

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John R

Read 29 C.F.R. Section 2560.503-1.

If you have determined that the program is an ERISA Title I plan, you must identify the fiduciary responsible for adjudicating claims. In a GTL setting, it's probably the insurance company, who by contract accepted the delegation of this fiduciary responsibility. Of course, this can be ambiguous. The insurance company may want to take the position that it's not a fiduciary with respect to the plan, although it performs the initial claims review function.

In addition to the regulation mentioned by Kirk, you should review the claims procedure in the policy or plan document. While these documents may simply repeat the regulation's minimum requirements verbatim, they may have provisions that impose speedier determination procedures on the fiduciary.