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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law


SPD's for FEHB

FEHB Open Season and FSA Open Season


Federal Employees Health Benefit Plan


Federal Employees Health Benefits Program
FEHB Plan Brochures


Links to Plan Brochures for 2003


Links to Plan Brochures for 2004


Links to the FEHB Open Season for 2005 Brochures



Federal Employees Health Benefits Program




TRICARE Handbook



SPD's for NJ State


for employees and retirees

January 2003  (pdf)


U.S. Healthcare Crisis Turnaround?

U.S. A.

Drs. & Hospitals Employers

$1.0 Trillion / Year

$$$ ERISA $$$

50% Savings

The Only Company with Compliant Solutions for All of You

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2
US Supreme Court Visits

at 11:57:03 AM on Friday, November 21, 2003


New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou,

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans

DOL Seal - Link to DOL Home Page



(Links to DOL) ©2010, Jin Zhou,

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]



Employee Retirement Income Security Act — ERISA

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)


New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & Treasury    08/05/2010  Hanover Park, IL

New Webinars, Seminars & Certification Classes Were Announced by for New Federal Appeals Regulations Issued on July 22, 2010 by HHS, DOL & Treasury for 193 million Americans. Effective 09/23/2010, New Federal Reimbursement Laws Mandate ERISA Internal Appeals and NAIC External Appeals For All Group and Individual plans With Six New & Most Powerful Consumer Protections

DOL Seal - Link to DOL Home Page



Patient Protection and Affordable Care Act



DOL Seal - Link to DOL Home Page

Frequently Asked Questions  
Search / A-Z Index

EBSA (Formerly PWBA) Final Rules

DOL Home > Rulemaking > Federal Register Documents (Selected Only, Click DOL Links for Updated Official Documents)

Legal Research Resources -Wirtz Law Labor Library

Interactive Tools

2004 Form 5500 Instructions

Schedule A - Insurance Information View  View - 2009 - 2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars, - 2010 ERISA Claim Specialist Certification Programs in Chicago, Illinois


New ERISA Appeal Book with 2010 Major Updates  $450  & $150 (Updates only with previous purchase) - ERISA Litigation Support, Facts + Laws + Strategies = Winning Lawsuit When Inevitable - Free ERISA Webinar, The Beginning for $6 Trillion Healthcare Denial Management Market


ERISA Power Guides
(Copyright © 2004 by Jin Zhou,

What You Should Know about Filing
Your Health Benefits Claim (Claims Card)

Filing A Claim For Your Health Or Disability Benefits (PDF)

Patient's Rights Claims Procedure Regulation (Fact Sheet)
Benefit Claims Procedure Regulation (FAQ)
New Federal Claim Regulation (Final Rule)
Amendments to Summary Plan Description Regulations (Final Rule)

New & Interactive From DOL
New @ elaws

Health Benefits Advisor

DOL/EBSA Organization Chart/Regional and District EBSA Offices | By Topic | By Audience | By Organization | By Location  



The White House News: New ERISA Chief for USA:  


"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor for Employee Benefits Security, Department of Labor"


Excerpt: "Until January 1995, [Phyllis] Borzi served as pension and employee benefit counsel for the U.S. House of Representatives, Subcommittee on Labor-Management Relations of the Committee on Education and Labor. She was on the Committee staff for 16 years. . . . . Borzi has published numerous articles on ERISA, health care law and policy and retirement security issues and is a frequent speaker on programs sponsored by legal, professional, business, consumer and state and local governmental organizations. An active member of the American Bar Association, Borzi is the current chair of the ABA's Joint Committee on Employee Benefits . . . ."

Excerpt: "President Obama on Tuesday during a prime-time news conference linked issues within the U.S. budget in part to high health care costs, stating that 'almost every single person' who has examined the nation's budget has concluded that the government must find a way to reduce health care costs, the Washington Post reports (Shear/Wilson, Washington Post, 3/25)."

Comments from Jin Zhou:


Fixing healthcare without addressing ERISA, the law 100% governing more than 90% of non-Medicare claims in USA, is Impossible - Jin Zhou


ERISA laws will be definitely enforced by this new ERISA Chief.....


ERISA appeals and practice will mean more than ever before....



DOL 2005 Advisory Opinions

2005-16A, 06/10/2005, ERISA Sec. 503

Dr. Gary Conant
Conant Chiropractic Clinic

Description of Request

Regarding the claims procedure regulation at 29 CFR 2560.503-1(h)(3) which requires the plan's named fiduciary deciding an appeal of a group health claim denied based on a medical judgment to consult with a physician or other health care professional that is licensed, accredited or certified to perform specified health services consistent with State law.


Enforcement News from DOL

Employee Benefits Security Administration


Fact Sheet - EBSA Achieves Total Monetary Results Exceeding $1.7 Billion

 (DOL, January 2006)

"Through its enforcement of the Employee Retirement Income Security Act (ERISA), the Employee Benefits Security Administration (EBSA) is responsible for ensuring the integrity of the private employee benefit plan system in the United States. EBSA’s oversight authority extends to approximately 730,000 pension plans and another 6 million health and welfare plans. These plans cover approximately 150 million workers and their dependents and include assets of more than $4 trillion.......


Record $88.4 Million Restored to Workers through Informal Complaint Resolution


When workers experience a problem with an employee benefit plan, EBSA has proven effective in resolving their requests for assistance. In FY 2005, EBSA’s Benefits Advisors handled nearly 160,000 inquiries and recovered $88.4 million in benefits on behalf of workers and their families through informal resolution of individual complaints. Many of these inquiries were received via EBSA’s toll-free number: 1.866.444.EBSA (3272) and Web site:


These inquiries are also a major source of enforcement leads. When EBSA becomes aware of repeated complaints with respect to a particular plan, employer, or service provider, or when there is information indicating a suspected fiduciary breach, the matter is referred for investigation. In FY 2005, 1,067 new investigations were opened as a result of referrals from Benefits Advisors."

FAQs about the UnumProvident Settlement

"What is the UnumProvident Settlement about?

The insurance regulators of all fifty states, the District of Columbia, and American Samoa participated in an examination of the claims handling practices of Unum Life Insurance Company of America, The Paul Revere Life Insurance Company, and Provident Life and Accident Insurance Company, the three disability insurers owned by UnumProvident Corp. The U.S. Department of Labor conducted a related investigation of UnumProvident’s practices involving employee benefit plans covered by the Employee Retirement Income Security Act. As a result of the examination and the DOL investigation, the three UnumProvident companies mentioned above plus First Unum Life Insurance Company, their New York affiliate, entered into a Settlement Agreement requiring the companies to change their claims practices and to reassess certain long term disability claims going back as far as 1997."

Advisory Opinions: 2005-02A, ERISA Sec. 103,  02/24/2005

"Regarding the Schedule A (Form 5500) requirements for reporting fees and commissions paid to brokers, agents and other persons directly or indirectly attributable to policies or contracts placed or retained with or by an ERISA-covered employee benefit plan."

Final Regulations for HIPAA Health Coverage Portability Model Certificate Press Release

Health Care Continuation Coverage; Final Rule [Rules and Regulations] [05/26/2004] | [PDF Version]| [Notices] | [Press Release]


U.S. Labor Secretary Elaine L. Chao Announces Stronger Retirement, Health Benefit Security for American Workers - 121% Increase in Monetary Results Shows “Commitment to Protect Hard-Earned Benefits” Release Date: 10/21/2004

"EBSA closed 4,399 civil investigations in FY 2004. Nearly 70% of those investigations resulted in correction of violations under the Employee Retirement Income Security Act (ERISA). Criminal investigations led to the indictment of 121 individuals. In addition, EBSA received a record 474 applications to participate in its compliance assistance program to help employers and plan officials to voluntarily correct specific violations of the law."

"This legislation is especially necessary for the nation's millions of small businesses, creating a level playing field and giving them the same benefits of administrative savings, negotiating clout, and uniform regulation enjoyed by large businesses and labor unions."

EBSA Achieves Record $3.1 Billion in Fiscal Year 2004 Results Press Release


"Atlanta, Georgia - The U.S. Department of Labor has obtained a preliminary injunction removing the trustees of the Paramount, California-based International Union of Industrial and Independent Workers Benefit Fund (IUIIW) and permanently barring them from service to the fund."


DOL Health Benefits Education Campaign [New  Seminars: IL, NY, KY]

DOL Launches National Education Campaign "Getting It Right-Know Your Fiduciary Responsibilities"


Labor Department Releases Form 5500 Annual Report and Filing Requirements for 2004


Press Release  EBSA News Release: [05/18/2004]


DOL Advisory Opinion on Certain Contributions to Health Savings Accounts (HSAs) (U.S. Employee Benefits Security Administration)


Employee Benefits Security Administration Issues Field Assistance Bulletin on Health Savings


Field Assistance Bulletin 2004-1 "Whether Health Savings Accounts established in connection with employment-based group health plans constitute "employee welfare benefit plans" for purposes of Title I of ERISA?"


Text of Final HIPAA Portability Regulations (PDF) (Internal Revenue Service, Employee Benefits Security Administration, Centers for Medicare & Medicaid Services)


Final Regulations for HIPAA Health Coverage Portability Model Certificate Press Release

Seminars are scheduled for Florida, Ohio, Massachusetts and Arizona, beginning in June 2004. The program will emphasize the obligation of plan sponsors and other fiduciaries to:

  • Understand the terms of their plans;

  • Select and monitor service providers carefully;

  • Make timely contributions to fund benefits;

  • Avoid prohibited transactions; and

  • Make timely disclosures to workers and their beneficiaries and reports to the government.


Meeting Your Fiduciary Responsibilities

Understanding Retirement Plan Fees And Expenses

Selecting An Auditor For Your Employee Benefit Plan

Reporting and Disclosure Guide for Employee Benefit Plans


State Insurance Department in All 50 States

Promote & Coordinate with ERISA  "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

NAIC ERISA Working Group


Health Benefits Laws By State
(Interactive Tools From

Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF)
(Council for Affordable Health Insurance)


Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University)

View a 5-minute clip

Paper Chase "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance - U.S. Health-care Crisis
& ERISA Criminal Enforcement

To Avoid "John Q.


What You Should Know
about Filing Your Health Benefits Claim
(DOL Claims Card)


 Organization Chart/Regional and District EBSA Offices



ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,


Medical Killing
Medical Inflation
Insurance Robbery
"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

Read Making a Killing




Bar graph showing trends in hospital charges and revenues in California from 1995-2002







American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

One Nation under Debt: U..S. economy threatened by aging of America


Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks


GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)


Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2


The Root of U. S. Healthcare Crisis

Jin Zhou,

The Hearing at Senate Committee on Finance on 3-3-04, [View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (]  revealed the mechanism, nature and extent of ERISA failure and nonenforcement as the reasons for "Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners", as being concluded as "No the results are not good. It’s a tragedy." by Ann Combs, assistant secretary of DOL. The mechanism, nature and extent of ERISA failure and nonenforcement as presented at the Hearing are universally true and applicable to all health care claim denials and delays in managed care environment from all employer sponsored health plans as the root of U. S. healthcare crisis.


This is a 911 call on "healthcare 9/11 disaster"!



Who Can Be a Medical Reviewer under ERISA?
(Copyright © 2004 by Jin Zhou,

Docket for 03-83


  02-1845. Aetna Health Inc. v. Davila 03/23/04

"QUESTION: Mr. Estrada, you can address what you would like but there are three points that have come up during the Respondent's presentation that I'd be interested with a response to.


Number one, is it true that the people who make the decisions for your client must be medical doctors in Texas?


MR. ESTRADA: Well it is true by virtue of DOL regulations which provide that no claim may be turned down without input from a medical professional in the relevant area"

New Federal Claim Regulation (Final Rule)

  1. "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)]

  2. "The term `health care professional' means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law." [page 70271 CFR § 2560.503-1(m)(7)]  


  • "medical doctors in Texas" = MD licensed to practice medicine in Texas for a Texas ERISA case;

  • "a medical professional in the relevant area" = relevant area of state laws in license jurisdiction, scope of practice and relevant local standard of care;

  • "licensed" = licensed by the State Government/licensing board;

  • "to perform" = to practice medicine or health care services in the State;

  • "specified health services" = medical procedures or services being reviewed or denied, instead of file review or insurance coverage reviews services;

  • "consistent with State law" = consistent with State laws where  the health care professional is legally licensed to practice medicine or health care services with respect to state jurisdictions,  scope of license and state local medical standard of care.


"The term `health care professional' means, in layman term,  a physician or other health care professional who is at least licensed in your state (and more, board certified too) to practice the specified/specific health services being reviewed or denied of your claims, consistent with your state law jurisdiction, scope of practice and local medical standard of care. Someone who is not licensed to practice the same health care services specified/denied in your claims is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).


Someone who is not licensed in your state to practice "specified health services" but who is merely registered under state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization Reviews (UR) is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).


    U.S. Supreme Court visited in regard to ERISA § 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this No. one point. Click here for more coverage of Supreme Court Visiting at




Labor Secretary Renames Agency Administering Retirement and Health Benefits

Labor Department Sues Corporation For Violating Federal Employee Benefit Law
(Release Date: 02/02/2004)

"Columbus, Ohio - The U.S. Department of Labor has sued defunct General Clay Products Corporation, of Columbus, Ohio, for abandoning the company’s retirement plan, and also filed suit against its president for failing to forward employee contributions to the health plan. The alleged violations resulted in the loss of health insurance coverage for company workers."

Labor Department Issues Reporting And Disclosure Guide for Employee Benefit Plans (11/20/2003)  

Reporting and Disclosure Guide for Employee Benefit Plans (U.S. Department of Labor Employee Benefits Security Administration)  pdf

Text of DOL Field Assistance Bulletin: Voluntary HSAs Generally Not ERISA-Covered Plans (U.S. Department of Labor, Employee Benefits Security Administration)


EBSA (Formerly PWBA) Final Rules

DOL Home > Rulemaking > Federal Register Documents
(Selected Only, Click DOL Links for Updated Official Documents)

Legal Research Resources -Wirtz Law Labor Library

Interactive Tools

DOL Home > EBSA  EBSA Final Rules      









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U.S. Department of Labor
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Washington, DC 20210

TTY: 1-877-889-5627
Contact Us



EBSA (Formerly PWBA) Final Rules

DOL Home > Rulemaking > Federal Register Documents (Selected Only, Click DOL Links for Updated Official Documents)







bullet Labor Department Rule Expands Electronic Disclosure Options For Employee Benefit Plans [04/08/02]



bulletDOL Publishes Revised Guide: MEWAs Under ERISA-- a Guide to Federal and State Regulation (PDF) (U.S. Department of Labor, Pension and Welfare Benefits Administration)

79 pages; revised September, 2002. Excerpt: "The first part of this booklet ... focuses on what constitutes an ERISA-covered plan and the regulatory and enforcement authority of the Department of Labor over such plans. The second part ... focuses on what is and what is not a MEWA and the extent to which states are permitted to regulate MEWAs that are also ERISA-covered welfare benefit plans."


A New Diagnosis & Solution:

ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings!

HMO Crisis Is Really An ERISA Crisis!

HMO & PPO Managed Care Contracting to 
Disregard & Substitute
ERISA SPD & Claims Procedure
Is The Primary & Inevitable Cause of Medical Inflation

Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!


ERISA Failure Damages Are Greater Than
9/11 and Pearl Harbor Tragedies Combined

U.S. Health-care Crisis & ERISA Criminal Enforcement


Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right" - "John Q. ERISA Enforcement".

The Rule of the Game for
80% of health-care claims and
60% of U.S. healthcare expenditures

A $1.0 Trillion Nuclear Solution to Our Nation's Health-care Crisis

Healthcare Providers:


    In a letter from Republican Congressional leader, John Boehner, to the Secretary of Labor and insurance/benefits industry, he states that "specifically, we are concerned about provisions in the final rule that go even further than the patients' rights bills passed by the Congress", and he urged DOL to revise and  delay the entire claims regulation.


    New rules for 80% of health-care claims of your business bottom-line, 90 percent of the new regulation protecting health-care providers, have arrived without welcome from our community after we have been struggling desperately and fighting with political contributions for new protections for decades.  Whenever our claims were denied by an insurance company/ERISA plan, we complained that insurance companies or ERISA plans do not play by rules and spent millions to lobby for new rules and new protections.  Now that the new rules are here, we do not care about them at all.  We do not know the name of the game, we do not know the rule of the game at all.


    About 90 percent of the new regulation is protecting/favoring health-care providers, but health-care providers nationwide failed or refused to learn about this protection they have been fighting for many years in federal and state courts through association lawsuits. The most state and national medical associations are focused or gambling in state and federal courts for the results/protections already provided by this new federal regulation but showed no interest or failed to realize this "oxygen for managed care critical conditions!"


    Listen to what experts in the industry or battlefields have to say, most of them are legal experts advising insurance companies and ERISA plans, in compliance with federal rules in making claim denials.  Or they study the rules and use the rules to their advantages in their compliance practice.


    How many medical/health-care provider associations, hospital associations, academic or advocate groups studied, educated you and complied with these new rules?  We need to wake up, know the rules and play by rules to our advantages in our compliance for our daily business bottom-line and survivals.


    Detailed and specific discussion of this new regulation emphasizing protections for health care providers are available through Seminars, ERISA for Physician (CD Book & System) and In-house Consulting as well as Executive Brainstorming from


    Without sufficient understanding of ERISA, health-care providers may never understand this new Federal Claim Regulation and Guidance.


   Aetna (DOL/ERISA), First Health, Blue Cross Blue Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI) (BCBSCNY) (BCBSNE) (CareFirstBCBS) & (BCBSAL),  are you ready to get paid faster and fairer?


   From Aetna's ERISA yesterday (Aetna Video Shows ERISA Patients Mistreated) to Aetna's ERISA today (DOL/ERISA) = Aetna ERISA Actions or intention in compliance and in control.


    From AMA's ERISA yesterday (The latest Harvard & RAND study) to AMA's ERISA today (JAMA Editorial) =ERISA Actions or Not?


    That's why physicians, healthcare providers and hospitals must wake up on ERISA now!


    AMA has finally noticed the existence and effective date of this new federal claim regulation, as described in its January 20, 2003 online edition of American Medical News: "Federal regulations that dictate rapid turnaround times for health plan claims and appeals quietly went into effect this month, with little noise from the managed care industry."

    However AMA has failed, as it did in past 28 years, to practically and meaningfully understand the ERISA and its significance as protections for health-care providers, entire industry has failed to offer any educational programs and occupational trainings to health-care providers in this most important federal law and regulation that governs and regulates up to 80% of health-care claims and 60% of U.S. healthcare expenditures.


    As reported by AMA as to the time it may take for this new federal claim regulation to take effect in marketplace, Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho, states "it often takes years, even decades, for the marketplace to fully adopt new regulations". Life is too short, our nation's health-care system is going through the worst crisis since World War II and can't afford another 28 years to realize and implement the ERISA regulations. We, everyone including health-care providers, legislators, regulators and insurance companies, should take immediate actions to educate everyone in the system and to implement this new federal claim regulation as we are fighting against terrorists to save our nation's health-care system from worse-than-terror-war crisis.


    Our seminars are for everyone, physicians, health-care providers, clinics, hospitals, insurance companies, ERISA plans, third party claim administrators and plan sponsors as well as state insurance regulators.




Industry Resource


   Aetna (DOL/ERISA), First Health, Blue Cross Blue Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI) (BCBSCNY) (BCBSNE) (CareFirstBCBS) & (BCBSAL),  are you ready to get paid faster and fairer?


2004 Reporting and Disclosure Calendar for Multiemployer Plans Online from the Segal Company (The Segal Company)



2004 Reporting and Disclosure Calendar for Single Employer Plans Online from the Segal Company (The Segal Company)


What Sites Do You Visit To Keep Up with Employee Benefits Compliance and Design Developments? (BenefitsLink Wiki)


ABA Joint Committee on Employee Benefits Agency Q-As


ABA Reports Various Employee Benefit Regulators' Views on Health Issues (Deloitte's Washington Bulletin)



The Segal Company's 2005 Reporting & Disclosure Compliance Calendar for Multiemployer Plans (The Segal Company)

The Segal Company's 2005 Reporting & Disclosure Calendar for Multiemployer Plans in Printable Form (PDF) (The Segal Company)

Nixon Peabody's August 2004 Benefits Briefs: Legal Developments for Employee Benefits (PDF) (Nixon Peabody LLP)

6 pages. Articles include: Getting burned by ignoring people with 'colorable' claims to plan participation; Court holds that ERISA forbids a plan from recouping excess benefit payments in court; Anti-cutback rule KOs suspension of benefits amendment.

Nixon Peabody's September 2004 Benefits Briefs: Legal Developments for Employee Benefits (PDF) (Nixon Peabody LLP)

7 pages. Articles include: What's discrimination in the design of ERISA plans?; Elect-it-yourself tax treatment for disability benefits; Insurance companies as plan fiduciaries; Retiree health benefits--Vested or not?

COBRA's Bite (

Excerpt: "[T]he consequences for a company that makes a mistake in following the new [notice] rules can be significant. In May, for example, a Nebraska federal judge fined a human resources company $307,000 for failing to provide an ex-employee with the proper COBRA notice. The court assessed the maximum statutory penalty of $110 per day for each beneficiary ... as well as their actual medical expenses. Attorneys' fees and costs may be awarded later."

Employer Health Plan Nightmares ... and Other Things That Go Bump in the Night (Chang Ruthenberg & Long PC)

Excerpt: "[I]f you can identify the intended benefits, the intended beneficiaries (e.g., employees and their families), and a procedure to apply for and receive benefits, then you probably have one or more ERISA welfare plans. Your company's welfare plans may be 'wrapped' together as one plan, or the company may have multiple welfare plans. Even if the benefits are provided solely by insurance contracts, there is a good chance that the company is the sponsor of an ERISA welfare plan."

Taking Advantage of DOL Guidance to Identify and Correct Gaps in Health Plan Compliance (PDF) (The Segal Company)

4 pages. Excerpt: "All of the laws discussed in this Executive Letter apply to group health plans and health insurers. In general, there are no distinctions in compliance obligations [under the federal laws discussed in this Executive Letter] for a self-insured plan versus a fully insured plan."

Preventive ERISA Compliance Medicine for Health and Welfare Plans (PDF) (Milliman USA)  At pp. 1-3 of 12-page document.



Overview: Proper Handling of ERISA Benefit Claims (ERISA Controversy Report, by Reish Luftman Reicher & Cohen)

Excerpt: "Claims by individual participants for plan benefits have long been the 'bread and butter' of ERISA litigation, and continue to represent the vast majority of cases filed. This article outlines some common-sense tips for employers, administrative committees and the members of those committees whose job it is to respond to benefit claims."

Summary Plan Description Deadline Is Here (PDF) (Trucker Huss)

Excerpt: "[T]he final SPD regulations are now fully effective. Plans were required to comply with the new SPD content requirements no later than the first day of the second plan year beginning after January 20, 2001: January 1, 2003 for calendar year plans. If you have not already done so, it is imperative that you review your SPDs to ensure that they contain all of the information now required under DOL Regulation § 2520.102-3."


Clinton Administration Pushes for Revolutionary Benefit Claims Final Rule for Erisa-Regulated Plans, Daly Temchine, October 27, 2000 (

Excerpt: "Given the revolutionary nature of this proposed claims regulation, welfare and pension plan sponsors and administrators need to be on the lookout for the final adoption of this regulation and of its consequences to their plans."


Regulating ERISA Claims Procedures: New Rules for Handling Benefit Claims (Paul, Hastings, Janofsky & Walker LLP)

Excerpt: "The chances of defeating most ERISA lawsuits can be greatly enhanced by effective use of the plan’s ERISA-required claims procedures. Effective utilization means..."

Analysis: DOL Guidance on Complying with the ERISA Claims and Appeals Regulation (PDF) (The Segal Company)

11 pages. Excerpt: "Starting this year, all employee benefit plans governed by the Employee Retirement Income Security Act (ERISA) must comply with the claims and appeals regulation issued by the Department of Labor (DOL) in November 2000. Plans affected include most retirement, health and welfare plans sponsored by an employer, union or joint board of trustees."

DOL Finalizes Major Changes to ERISA Regulations (PDF) Open this result in new window (SEYFARTH SHAW)

8 pages. Excerpt: "Late last month, the United States Department of Labor ("DOL") issued final regulations in response both to President Clinton’s health care reform directives and more than 700 letters of comment that addressed the DOL’s previous proposal. The final regulations:

• completely overhaul ERISA’s claims procedures for group health plans and disability plans and, to a lesser extent, for pension and other welfare benefit plans, and

• extensively amend the disclosure requirements for summary plan descriptions ("SPDs") for all plans."

Ringing in the New Rules (PDF) (Gardner Carton & Douglas)

A Service to Our Clients and Our Friends

DOL guidance could help plan sponsors confronting

the new ERISA claims procedure regulations

Excerpt: "It will not rank up there with bad fruitcake or silly hats and noisemakers, but the Department of Labor ("DOL") may be starting a holiday tradition of its own – weighing in with new ERISA claims

procedure guidance.Just weeks before the claims procedure rules it finalized before the holidays last year take effect for disability and other non-health plans, the DOL has issued informal question-and-answer guidance that should prove very useful to plan sponsors."

2002: the Claims Odyssey Continues (PDF) (Gardner Carton & Douglas)

Excerpt: "All ERISA disability plans, even those with non-calendar year plan years, [are] required to comply with the new rules for claims submitted on or after January 1, 2002.... The new claims procedure rules take effect for claims filed under an employer's health plan for plan years beginning on or after July 1, 2002, but not later than January 1, 2003 (for calendar year plans, the rules will be effective for claims filed on or after January 1, 2003)."

DOL Issues Final Rule on SPD Content Requirements (Groom Law Group)

Excerpt: "There are no big surprises in the final rule, as it largely adopts the changes set forth in the DOL's proposed rule issued on September 8, 1998. The final rule's primary focus is on SPD requirements pertaining to group health plans, although the rule also identifies and clarifies SPD requirements for pension and other welfare benefit plans."

Department of Labor Issues Final Claims Regulations (7/1/2001) (Groom Law Group)

Excerpt: "The final rule does contain some significant improvements compared with the proposed rule. For example, it distinguishes between prior authorization claims and retrospective review claims and has different time frames for both. (The proposed rules treated all non-urgent claims the same.) ......The final rule also has a more reasonable effective date than the proposed rule, allowing plans more time to prepare for compliance.
Even so, the final regulation is a major departure from the current rule. In addition, DOL included several new requirements that were not found in the proposed regulation. We discuss below a summary of the final regulation, focusing on group health plans, and highlight areas that are likely to cause significant compliance burdens."

Administering Health and Disability Plans Under DOL's Final Regs on Claims Procedures and SPDs (PDF) (Pillsbury Winthrop LLP)

Excerpt: "The claims and appeals procedures will apply with respect to claims for benefits filed on or after January 1, 2002.... The claims procedures set forth in the final regulation must be followed closely. If a plan fails to establish or follow claims procedures consistent with the regulations, the claimant is deemed to have exhausted the plan's administrative remedies and is entitled to pursue any available remedies under Section 502(a) of ERISA."

DOL Makeover for Health Benefit Plans' Claims Procedures and Summary Plan Descriptions (McDermott, Will & Emery)

Excerpt: "Compared to the current rules, the new rules require (a) greater disclosure to participants of plan claims procedures and provision to claimants of the complete and specific reasons for any claim denials and all information relevant to such denials; (b) more procedures intended to assure fair treatment of claimants and (c) faster decisions on both initial claims and appeals of denied claims."

Benefits Claims Defenses (pdf) (McCalla Thompson)

Excerpt: "This paper is a survey of virtually the entire body of federal case law on benefit claims under ERISA Topics covered include the new claims regulations, exhaustion of plan administrative remedies including the adequacy of the process and exceptions to the exhaustion requirement, standards of review of fiduciaries' benefit claim decisions."

Department of Labor Amends ERISA Regulations Governing Benefit Plans’ Claims Procedures and Content (McCalla Thompson)

Excerpt: "These revisions will require Plan Sponsors to formally adopt changes to claims procedures, revise SPD's to reflect the changes mandated by both revisions and create new procedures for processing claims. More importantly, training employees in the new requirements for handling claims will be critical to maintaining compliance."

DOL Revises Claims Procedures and SPD Regs (PDF) (Aon Consulting)

Summary of new rules, with chart of claims procedure deadlines.

ebsa Delays Applicability Date of Claims Procedures Rules For Group Health Plans Only (Spencernet)

The Department of Labor's Pension and Welfare Benefits Administration (ebsa) has delayed 'for at least six months and not more than one year' the applicability date for its final regulations under ERISA Sec. 503 governing benefit claims procedures of group health plans. Notice of the delay was published in the July 9 Federal Register.


Summary of Final Regulation on Requests by DOL for SPDs, Plan Documents (BenefitsLink Message Boards)

Link to a brief article and discussion on our message boards; please join in if you have a comment about the final regulation.


Analysis: DOL Finalizes Regulations With Penalties for Failure to Produce Documents on DOL's Request (EBIA Weekly)

Excerpt: "The DOL's request for documents is limited to documents that a participant or beneficiary could examine and obtain ... 'Participant or beneficiary' is broadly defined for this purpose, specifically including even prospective alternate payees (under a qualified domestic relations order), prospective COBRA qualified beneficiaries, and prospective alternate recipients (under a qualified medical child support order)."

Furnish Documents to DOL in 30 Days or . . . (Kilpatrick Stockton LLP)

Excerpt: "TRA '97 also gave the Department authority to assess penalties on a plan administrator that fails to provide the Department with the requested documents within 30 days of the request .... [F]inal regulations were issued on January 7, 2002, effective March 8, 2002."

Significant Delay in Application of New Claims Procedure Regulations--But Only for Group Health Claims (EBIA Weekly)

Excerpt: "The deadline to comply with the DOL regulations on claim procedures has been extended, but only for ERISA group health claims. There is no extension provided for disability and other ERISA claims, including those under 401(k) and other pension plans. These plans must comply with the new rules by the original applicability date (i.e., for these plans, the new rules apply to claims filed on or after January 1, 2002)."


What Information Must Go Into Group Health Plan's SPD? (EBIA Weekly (Question of the Week))

Excerpt: "[U]nder DOL Reg. Sec. 2520.102-3(j)(3), the SPD for a group health plan is required to contain a description of the following laundry list of specific items relating to benefits ... [S]ubject to one exception, the regulations specifically allow detailed schedules of benefits to be described generally in the SPD, if the SPD refers to the schedules of benefits and explains that they are available without charge to any participant or beneficiary who requests them."

New HIPAA Privacy and ERISA Claims Review Rules: 10 Reasons To Comply (Brown Rudnick Berlack Israels L.L.P.)

Group Health Plan Compliance with ERISA and HIPAA: Navigating the Legal and Administrative Maze (PDF) (Brown Rudnick Berlack Israels L.L.P.)

72 pages. A 'Question and Answer Resource Guide."


Full Text: Group Health Plan Compliance with HIPAA and ERISA (PDF) (Brown Rudnick Berlack Israels LLP)

73 pages include 'Questions and Answers Relating to HIPAA,' 'Questions and Answers Relating to the New Claims Review Regulations,' 'Questions and Answers Relating to Group Health Plan Document, Summary Plan Description and Document Disclosure Requirements."







A New Diagnosis & Prescription for
Our Nation's Health-care Crisis



    Contrary to the popular belief,  our nation's health-care crisis has been truly and mainly caused by the lack of understanding and failing in compliance with ERISA, the federal law regulating about 80% of health-care claims or 60% of health expenditures in the U. S. by both insurance/benefits industry and health-care providers for 28 years, through reckless and fraudulent as well as revengeful, inflationary spiral billings and claim denials that destroyed or foreclosed the hope, faith and the Law & Order for our nation in health-care quality and cost control, and the lack of meaningful and practical federal administrative enforcement of ERISA claim regulations, because this inflationary spiral skyrocketing increases in managed care claim and denial war behind ERISA shield between health insurers/ERISA plans and healthcare providers have overwhelmingly outnumbered increases in cost of living and national gross domestic products, causing annual double-digit increases in health insurance premiums and skyrocket health-care costs ($1.55 trillion in 2002, 14.9% of the U.S GDP) after every managed care strategy and model failed to contain or control health-care costs in long run despite short-term savings, while entire country has devoted more and more money in litigation, legislation and noncompliant managed care campaign, which practically have solved little or no problem.


    In order to resuscitate U.S. Healthcare/managed care from such a critical condition, the strategy and solution must to be a common ground acceptable to all parties involved, instead of hostile and contradictory debate of punitive damage therapy vs. the uninsured coverage in Congress. This common ground for our national health-care crisis is the ERISA Claim Regulations, applicable and existing laws and regulations on the book, originally designed by Congress in 1974 to regulate health-care claim dispute and to avoid fiduciary breach and failures we are facing today.


    A new practical and effective solution to saving our nation's health-care system is  to implement ERISA as Congress intended by creating a new occupation or profession, ERISA claim specialists and departments, t0 bridge the gap FROM medical billers and coders & insurance claim processors TO lawyers for both health-care providers and insurance companies/ERISA plans, and to educate everyone in  health-care and employee benefits system, health-care providers and their associations and leaders, IPA's, MCO's, health insurance, employee benefits TPA's and legislators as well as regulators to truly understand ERISA, and comply with existing ERISA's claim procedures and benefits administration rules, to make practical sense for health insurance delivered as employee welfare benefits under ERISA, protecting participants and beneficiaries and safeguarding plan assets through compliance of ERISA laws and regulations by everyone.


    How do we know this is the right diagnosis and prescription?


Plain and simple, imagine what would happen if the U.S. healthcare superhighway transported $1.55 trillion for 283 million Americans each year without an understanding, without compliance by any one and without the enforcement of any existing laws and regulations governing those 80% of the healthcare claims, 60% of the healthcare expenditures and 163 million Americans under ERISA?


The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care.


A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),10 which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."


This valuable study has pointed out the direction but failed to provide a turnkey practical solution. has provided this nation with a turnkey operational solution with ERISA compliance, to educate everyone on ERISA, coverage and claim procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan Sponsors and Insurers.


Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.

Sec. 1003.

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements


Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:



        Selected links:

2520.102-3 Contents of summary plan description.

Claims procedure.


Download Title 29, Chapter 18, of the United States Code ("Employee Retirement Income Security Act" or "ERISA") - From the U.S. House of Representatives downloadable U.S. Code.


Advisory Opinions

Advisory Opinion Archives





















Women's Health and Cancer Rights Act of 1998

Frequently Asked Questions


WHCRA Publication












Advisory Opinion 95-10A

Your correspondence concerns applicability of Title I of the Employee Retirement Income Security Act of 1974 (ERISA) to certain benefit plans for the University's employees. Specifically, you request an advisory opinion concerning whether those benefit plans are church plans within the meaning of section 3(33) of Title I of ERISA.



Advisory Opinion 96-14A

"Thus, it appears that the schedule of "usual and customary" fees described in your letter would be required to be disclosed to participants and beneficiaries in accordance with section 104(b)(2) and 104(b)(4) of ERISA."



Advisory Opinion 97-11A

" amended (ERISA), to furnish a participant with a copy of the contract between an employee benefit plan and a third party administrator (TPA)."



Advisory Opinion 97-21A

ERISA SEC. 4(b)(3)


"You ask whether ERISA § 4(b)(3), which excludes from ERISA plans that are maintained solely to comply with state-mandated disability benefits, would apply to a disability benefits program (hereinafter, the Program) offered by the Association of Independent Colleges and Universities in New Jersey (hereinafter, AICUNJ) to its members for their employees."



Advisory Opinions
 for 2002

Information Letter [08/23/02]

"Section 514(a) of Title I of ERISA generally preempts state law purporting to regulate an employee benefit plan covered under that title. There are, however, exceptions to this general preemption provision....

Accordingly, in the Department’s view, Title I of ERISA does not preclude Georgia from applying its insurance law to the IUIIW Fund as a MEWA in accordance with section 514(b)(6)(A) of ERISA, as described above.(1)"



Advisory Opinions

Employers Participating in MEWA Are Bona Fide Group or Association and Therefore MEWA Is a Single ERISA Plan


Advisory Opinion 2003-18A

"the Hospital Authority is a governmental agency,...... is a “governmental plan” within the meaning of ERISA section 3(32) and is excluded by ERISA section 4(b)(1) from coverage under Title I."

Text of DOL Advisory Opinion 2004-01A: Governmental Plan Definition (U.S. Department of Labor, Employee Benefits Security Administration)



American Benefits Council

Boehner Urges DOL to Delay New Claims Procedure Regulation for Group Health Plans (PDF)

"Specifically, we are concerned about provisions in the final rule that go even further

than the patients' rights bills passed by the Congress. For example, the Department's

final rule:..."



DOL Secretary Testifies to Committee About ERISA Enforcement, Compliance Assistance (U.S. Department of Labor, Pension and Welfare Benefits Administration)




GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

"What GAO Recommends:

The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

modifications and make them publicly available."





Federal Employees Health Benefits Program








Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."



An Employer's Guide to Employee Benefits, 2004 Edition (PDF) (Briggs and Morgan, P.A. and the Minnesota Department of Employment and Economic Development)


Small Plan Sponsors Dangerously Ignorant of Duties (


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