The Legal and Regulatory Landscape of Disability Claims

Disability claims are governed by a complex set of regulations, including federal laws like the Employee Retirement Income Security Act (ERISA) and applicable state laws. These regulations require that disability decisions be fair, timely, and based on objective evidence.

Organizations that conduct disability reviews must adhere to these legal standards. They must also maintain secure handling of protected health information (PHI), as required by HIPAA regulations. Any failure to comply can result in penalties, lawsuits, or reputational damage.

Medical review organizations help employers stay compliant by ensuring that all processes follow applicable rules. They bring transparency, audit readiness, and legal defensibility to the disability claims process.

It is critical that the recommendation of a claim be legally sound and for the recommendation to be supported by medical evidence and clinical expertise. Professional testimony by a medical professional is sometimes utilized in the disability claim process. All areas of the review process can undergo legal scrutiny and review to ensure that an accurate and objective determination was made.