Prior to taking on a client,
ELAP requires that the prospective plan-document be reviewed by our
designated and exclusive specialist law firm. The review of the plan-doc
is not all-encompassing. Rather, the purpose of the review is to identify
certain crucial language in the plan-doc that ELAP believes could either
lead to benefit disputes or worsen a benefit dispute.
According to the recommendations of our attorneys, ELAP may ask the Plan
Sponsor to revise or amend its plan document. The goals are two-fold. The
first is to strictly comply with Federal Law. The second is to maximize
the clarity with which certain passages are written, so as to minimize
potential disputes due to ambiguity.
Here are the sections of the plan document that are certain to be
reviewed, as well as information regarding other program-related
documents:
- We use a Plan Amendment that
allocates the duty to make final benefit determinations to ELAP,
Inc., and it establishes ELAP, Inc. as a (limited) Fiduciary –
Designated Decision Maker (DDM) -- for the Plan. This Amendment
provides maximum legal protection to the plan sponsor and to ELAP,
and it is the ONLY Amendment that is non-negotiable – we must add
this to the Plan-Doc of our prospective client.
Click here to
view the DDM Plan Amendment. (Adobe
Acrobat Reader Required)
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For the purposes of strict compliance
with the DOL Claims Processing Regulations of July 1, 2002, our
attorney will review the section of your plan-doc that addresses a
participant’s rights to file Claims and Appeals. The
7/1/2002 DOL Reg is very specific, and failure to comply means a
participant can bypass the plan’s appeals process and go straight to
Federal court with a lawsuit. Our attorney will look for or add
compliant language.
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- So that a plan participant is fully
aware of his/her rights as a beneficiary of the Plan, our attorney
will look for or add a Statement of ERISA Rights.
- To be sure that the Plan complies
with all laws and regulations that might have jurisdiction over the
Plan, our attorney will look for or add a Conformity with
Applicable Laws provision.
- So as to prevent a participant from
having an infinite amount of time to file for legal remedies against
the Plan, our attorney will look for or add a Limitation on
Actions provision.
- To attempt to minimize the chances
of disputes on the FRONT-END, our attorneys will review and may
suggest revisions to certain exclusions and/or definitions,
such as:
-
Experimental/Investigational
- Medical
Necessity/Medically Necessary
-
Obesity/Obesity-related treatment
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- DDM Service
Agreement (our contract)
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Click here to
view a sample copy of our contract-for-services, which we sign
directly with plan sponsors. (Adobe
Acrobat Reader Required)
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Decision-Letters. These are obviously not a part of the
plan-doc, but ELAP prefers to write its decision letters directly to
the plan participants, with a copy to the Plan Sponsor (and TPA).
This allows us to assure that the plan participant is fully aware of
his or her rights, now that the DOL-mandated appeals-process has
concluded.
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