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What is a "Claim for Benefits" Under ERISA?

What is a “Claim for Benefits” Under ERISA? (Retirement Plans¹)

ERISA has strict requirements for responding to and processing “benefit claims,” including mandated “claims procedures” and specific timing and substantive rules for denials of claims by plans and appeals of denials by participants. However, it is not always clear what is or is not a “claim” or when a “claim” was made.

What is a claim for benefits?

The regulations under ERISA define a claim for benefits as a request for a plan benefit or benefits made by a claimant in accordance with a plan’s reasonable procedure for filing benefit claims. See 29 C.F.R. § 2560.503-1(e). All plans are required to have reasonable procedures for filing benefit claims. Those procedures should specifically describe the method for making a claim, whether the claim must be in writing and where it should be directed, as well as a reasonable method for designating a representative to handle a claim on behalf of the participant or beneficiary. [See DOL Information Letter]

What is not a claim for benefits?

An inquiry about benefits that does not request plan benefits under a plan is likely not a “claim for benefits.” So, if a participant asks for plan documents, an explanation of benefits, a benefit statement or plan disclosure, or just asks “why” something is the way it is, these inquiries are not likely “claims for benefits.” However, if the inquiry also includes a request for some payment, benefit,or action or inaction on the part of the plan or plan administrator, it may be a claim.

What should a plan administrator do if the plan receives a claim for benefits?

The plan should have internal procedures for handling benefit claims, which may include notifying the plan administrator or other person with discretion to decide the claim, involving counsel where needed, notifying an insurer if applicable, etc. Then the plan administrator should follow its own claims procedures.

What should a plan administrator do if they are uncertain whether a communication is a claim?

While there are exceptions, as a general rule, all requests from participants and beneficiaries should receive some sort of response. If it seems that no claim was intended, the response could include a statement to that effect, putting the participant on notice that the plan does not intent to treat the inquiry as a claim and asking the participant to respond if it was intended to be a claim.

© Boutwell Fay LLP 2019, All Rights Reserved.This handout is for information purposes only, and may constitute attorney advertising. It should not be construed as legal advice and does not create an attorney-client relationship. If you have questions or would like our advice with respect to any of this information, please contact us.The information contained in this article is effective as of May 31, 2019.


¹ This FAQ applies only to retirement plans. Additional specific requirements apply to claims for benefits under group health plans.

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