§ 85A-211. Denial of claim - Appeal rights.

A.  If an employer denies a claimant's claim for benefits under this act, the employer shall notify him or her in writing of the decision or the need for additional information within fifteen (15) days after receipt of the claim.  Unless otherwise provided by law, the adverse benefit determination letter shall contain an explanation of why the claim was denied, including the plan provisions that were the basis for the denial, and a detailed description of how to appeal the determination.  Additional claim procedures consistent with this section may be specified in the benefit plan.

B.  The benefit plan shall provide the following minimum appeal rights:

1.  The claimant may appeal in writing an initial adverse benefit determination to an appeals committee within one hundred eighty (180) days following his or her receipt of the adverse benefit determination.  The appeal shall be heard by a committee consisting of at least three people that were not involved in the original adverse benefit determination.  The appeals committee shall not give any deference to the claimant's initial adverse benefit determination in its review;

2.  The committee may request any additional information it deems necessary to make a decision, including having the claimant submit to a medical exam;

3.  The committee shall notify the claimant in writing of its decision, including an explanation of the decision and his or her right to judicial review;

4.  Subject to the need for a reasonable extension of time due to matters beyond the control of the benefit plan, the committee shall review the determination and issue a decision no later than forty-five (45) days from the date the notice of contest is received.  No legal action may be brought by or with respect to a claimant to recover benefits under the benefit plan before the foregoing claim procedures have been exhausted;

5.  If any part of an adverse benefit determination is upheld by the committee, the claimant may then file a petition for review with the Commission sitting en banc within one (1) year after the date the claimant receives notice that the adverse benefit determination, or part thereof, was upheld.  The Commission en banc shall act as the court of competent jurisdiction under 29 U.S.C.A. Section 1132(e)(1), and shall possess adjudicative authority to render decisions in individual proceedings by claimants to recover benefits due to the claimant under the terms of the claimant’s plan, to enforce the claimant’s rights under the terms of the plan, or to clarify the claimant’s rights to future benefits under the terms of the plan;

6.  The Commission shall rely on the record established by the internal appeal process and use an objective standard of review that is not arbitrary or capricious.  Any award by the administrative law judge or Commission shall be limited to benefits payable under the terms of the benefit plan and, to the extent provided herein, attorney fees and costs; and

7.  If the claimant appeals to the Commission and any part of the adverse benefit determination is upheld, he or she may appeal to the Oklahoma Supreme Court by filing with the Clerk of the Supreme Court a certified copy of the decision of the Commission attached to a petition which shall specify why the decision is contrary to law within twenty (20) days of the decision being issued.  The Supreme Court may modify, reverse, remand for rehearing, or set aside the decision only if the decision was contrary to law.

The Supreme Court shall require the claimant to file within forty-five (45) days from the date of the filing of an appeal a transcript of the record of the proceedings before the Commission, or such later time as may be granted by the Supreme Court on application and for good cause shown.  The action shall be subject to the law and practice applicable to comparable civil actions cognizable in the Supreme Court.

C.  If any of the provisions in paragraphs 5 through 7 of subsection B of this section are determined to be unconstitutional or otherwise unenforceable by the final nonappealable ruling of a court of competent jurisdiction, then the following minimal appeal procedures will go into effect:

1.  The appeal shall be heard by a committee consisting of at least three people that were not involved in the original adverse benefit determination.  The appeals committee shall not give any deference to the claimant's initial adverse benefit determination in its review;

2.  The committee may request any additional information it deems necessary to make a decision, including having the claimant submit to a medical exam;

3.  The committee shall notify the claimant in writing of its decision, including an explanation of the decision and his or her right to judicial review;

4.  The committee shall review the determination and issue a decision no later than forty-five (45) days from the date the notice of contest is received;

5.  If any part of an adverse benefit determination is upheld by the committee, the claimant may then file a petition for review in a proper state district court; and

6.  The district court shall rely on the record established by the internal appeal process and use a deferential standard of review.

D.  The provisions of this section shall apply to the extent not inconsistent with or preempted by any other applicable law or rule.

E.  All intentional tort or other employers' liability claims may proceed through the appropriate state courts of Oklahoma, mediation, arbitration, or any other form of alternative dispute resolution or settlement process available by law.

Added by Laws 2013, c. 208, § 118, eff. Feb. 1, 2014.