Filing a claim for benefits is a protected right.
Filing a health claim, appealing a denial or asking about coverage all use rights under the plan and ERISA. Here is how to respond to those requests without inviting a retaliation claim.
What the rules require.
Consider this a plain-language primer on claims and retaliation. It informs rather than advises, and regulations get updated, so look at the current rule text.
Protected Claim Activity
Submitting a claim, appealing a denial, requesting plan documents or complaining about a benefit all count as using a plan right that Section 510 protects (29 U.S.C. 1140).
Claims Procedure Rules
ERISA plans need a reasonable claims and appeals process with fixed timeframes, written denial notices that give reasons, and a full and fair review (29 U.S.C. 1133; 29 C.F.R. 2560.503-1).
Separate The Decision Makers
Under the plan terms, the plan or its claims administrator decides claims. The trouble starts when claim details are carried into employment decisions.
How it plays out at work.
Employees often talk to a supervisor or HR before they file anything. Train managers to point the employee to the claims process and to avoid commenting on the claim, the diagnosis or the cost to the plan.
Keep a firewall between claims information and personnel decisions. For fully insured plans the carrier decides claims, and for self-funded plans a third-party administrator usually does. Either way, the employer should avoid receiving individual claim detail beyond what is needed to administer the plan, consistent with HIPAA.
When an employee complains that a claim was wrongly denied, treat the complaint as protected, help them find the appeal steps in the plan documents and record that you did.
Where this shows up in your plan.
Plan Documents On Request
Participants can ask for plan documents. Answer inside the legal deadline and keep a request log. Our summary plan description guide shows what to hand over.
Appeals and Deadlines
A group health plan must give at least 180 days to appeal an adverse benefit determination under the claims regulation, and the denial notice should state the deadline.
Claims Data Privacy
Individual claim details are protected health information under HIPAA. Keep them out of hiring, firing and scheduling.
Setting it up.
Print the claims and appeals steps in the summary plan description.
Have managers send claim questions to HR or the carrier.
Keep employer visibility into individual claims narrow.
Keep a record of each document request and when you answered.
Run any adverse action against an employee with a claim or appeal pending past HR first.
Mistakes to avoid.
Telling an employee a big claim will push up the renewal.
Giving a supervisor claim detail that HR itself does not need.
Letting the deadline for a plan document request slip.
Reading a benefit complaint as insubordination.
Other rules employers work with.
Employer Guide to Whistleblower Protections
Where claims protections sit in the broader retaliation framework.
SPD Versus Benefits Guide Explained
Where the claims procedure belongs in your plan paperwork.
Mandatory Workplace and Benefit Notices
A checklist of the notices employers must furnish.
Laws and Rules Referenced
29 U.S.C. 1140 (ERISA Section 510) — The anti-retaliation section covering plan rights.
29 U.S.C. 1133 (ERISA claims procedure) — Written notice and review for denied claims.
29 C.F.R. 2560.503-1 (Claims procedure regulation) — The regulation setting claim timeframes, notices and appeals.
Employee Benefits Security Administration (U.S. Department of Labor) — EBSA resources for sponsors and participants.
Quick answers.
Common employer questions get concise answers here, and each one leads to the fuller guide.
Is filing a health claim protected activity?
Yes. Making a claim uses a right under the plan, and Section 510 forbids discrimination for doing so.
How long does a participant have to appeal a denial under a group health plan?
A minimum of 180 days after the participant receives the denial notice, per the claims regulation.
Can a manager see an employee’s claims?
As a rule, no. Keep employer access to what administration needs and follow HIPAA.
Is this page a legal opinion?
No. It covers the general rules; an ERISA attorney can apply them to your circumstances.
More guides in this series.
Michigan Whistleblowers’ Protection Act: Employer Guide
A companion guide in the same series.
ERISA Section 510 and Benefit Plan Retaliation: Employer Guide
A companion guide in the same series.
Federal Anti-Retaliation Laws Employers Should Know
A companion guide in the same series.
Leave, Reduced Hours and Retaliation Risk for Employers
A companion guide in the same series.
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