Health Insurance Claims Fairness Act of 1992

Health Insurance Claims Fairness Act of 1992 - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to establish procedural requirements for claims review for employee welfare benefit plans, including: (1) a time limit for consideration of completed claims; (2) a duty to review denials upon timely request; (3) a time limit for review; (4) a shortened time limit for consideration of requests for preauthorization in cases of services involving urgent treatment for a life-threatening illness or services with an aggregate value or expected value of more than $20,000; (5) automatic review, expedited exhaustion of plan remedies, and prohibition against denying previously authorized claims in such preauthorization cases; (6) a time limit for determining incompleteness of claim; and (7) additional notice and disclosure requirements for group health plans.

Prohibits employee welfare benefit plans from requiring any party to waive any right under the plan or ERISA as a condition of approval of any claim for benefits or any request for preauthorization of services under the plan, except as otherwise specified in a formal settlement agreement.

Directs the Secretary of Labor (the Secretary) to establish a welfare benefit claims assistance program within 180 days after enactment of this Act. Requires the Secretary, under such program, to make available ongoing assistance in the resolution of claims under employee welfare benefit plans to plan participants and beneficiaries. Requires such assistance to include; (1) reviewing denials of claims; (2) assisting in appeals; (3) contacting employee welfare benefit plans and insurance contractors on behalf of participants and beneficiaries; (4) assisting participants and beneficiaries in obtaining plan documents; and (5) referring cases for appropriate enforcement action.

Makes the terms of any settlement agreement entered into under the procedures established by an employee welfare benefit plan enforceable under ERISA as if they were terms of the plan.

Revises the definition of group health plan. Defines "insurance contractor" and "insurer."

Adds to disclosure requirements for employee welfare benefit plans to include: (1) any insurance contract under which benefits are or were provided; and (2) in the case of a group health plan, any fee or reimbursement schedules for health care providers under the plan.

Directs the Secretary to establish and maintain an Early Resolution Program (ERP) for employee welfare benefit plans, to be administered in the Department of Labor by a Claims Resolution Board (the Board).

Requires the Board to: (1) administer ERP in accordance with Board regulations; (2) develop ERP policy and procedures; (3) maintain rosters of arbitrators and facilitators to act for the Board in arbitration and mediation proceedings (and coordinate recruitment, selection, and training of such arbitrators and facilitators); (4) provide meeting sites, maintain records, and provide arbitrators and facilitators with administrative support staff; (5) establish and maintain attorney referral panels; and (6) monitor and evaluate ERP on an ongoing basis.

Sets forth requirements for Board membership, terms, Executive Director and staff, and quorum.

Sets forth conditions for eligibility of cases for submission to ERP, including criteria relating to the parties and the nature of the claim. Requires that submission to ERP be only after exhaustion of plan remedies and in lieu of commencement of civil action. Allows representation by a legal guardian or other court-appointed representative in cases of claimant incompetency.

Requires each employee welfare benefits plan, as part of its claims review procedure, to inform claimants, during their taking part in such procedure, of ERP's availability.

Directs the Board to recruit ERP arbitrators and facilitators from individuals with the requisite expertise for such service. Sets forth criteria for the Board to consider in selecting such individuals. Requires the Board to provide a training program for all new arbitrators and facilitators, with a curriculum including relevant procedures, ethical obligations, and dispute resolution skills. Requires individual completion of such training before service. Requires Board appointment of an arbitrator or facilitator (as appropriate) for arbitration of mediation proceedings on a submitted claim through a random procedure.

Allows parties to participate on their own behalf or be represented by attorneys throughout the arbitration and mediation proceedings under ERP. Directs the Board to maintain experienced attorney referral panels (both fee-paying and pro bono) and referral information regarding other sources of legal assistance.

Sets forth confidentiality requirements for arbitrators and facilitators in ERP proceedings. Sets forth conditions under which voluntary disclosure may be made by the parties. Provides for inadmissibility of information disclosed in violation of such requirements and conditions. Allows the parties to agree to alternative confidential procedures by an arbitrator or facilitator. Requires notice of demands for disclosure. Sets forth exceptions from such confidentiality requirements under specified conditions in the case of: (1) information otherwise disclosable; (2) documentation of agreements or organizations; (3) research or educational purposes; and (4) disputes between arbitrator or facilitator and a party. Authorizes the Secretary to assess a civil penalty against any person who discloses information in violation of such confidentiality requirements and conditions in an amount three times the claim amount. Disqualifies from further ERP service any arbitrator or facilitator who violates such confidentiality requirements.

Allows a claimant who is eligible for ERP to elect to use the arbitration procedure or the mediation procedure.

Establishes procedures for arbitration of disputes under ERP, including: (1) requirements generally similar to those for binding arbitration proceedings under other specified Federal law; (2) specific rules for notice, records, hearings, and evidence; (3) treatment of ex parte communications; (4) findings of fact; (5) award amounts, including legal costs, and additional penalties in certain cases; (6) enforcement of award; (7) precedential effect; and (8) judicial review.

Establishes procedures for mediation of disputes under ERP, including: (1) initiation of proceedings (with provisions for claimant's filing of election and agreement to participate and required participation and cooperation by plans and insurance contractors); (2) mediation proceedings in general; (3) an analysis stage; (4) an evaluation stage, with a conference, preparation of settlement agreement, evaluation upon initial failure to reach settlement, and encouragement of extension of proceedings if this is likely to lead to settlement or a substantial narrowing of the issues; (5) applicable time limits; (6) legal effect of participation in the proceedings; (7) inapplicability of formal rules of evidence, with the facilitator to be sole judge of the proper weight to be afforded to each submission; (8) inapplicability of oath requirements; and (9) court enforcement of settlement agreements, with provisions for rehearings, modifications or corrections, and appeals.

Sets forth the scope of court enforcement in cases of ERP arbitration and mediation, in relation to other ERISA requirements.

Requires compliance with requests for relevant information or documents by arbitrators and facilitators in ERP arbitration or mediation proceedings. Authorizes the Board to assess civil penalties for violations of information requirements. Provides for enforcement of civil remedies for violations of confidentiality requirements.

Sets forth deadlines for the Secretary's appointment of initial members of the Board and for the Board's issuance of initial regulations for ERP.

Provides that ERP provisions shall not apply to certain collectively bargained plans which already include, and continue to include, explicit procedures for resolution of claims disputes by arbitration, mediation, or both between participants and beneficiaries and the plan and any insurance contractors for the plan.

Revises ERISA title I (Protection of Employee Benefit Rights) enforcement provisions to provide for recovery of damages for failure to provide benefits as required under an employee welfare benefit plan. Makes the named fiduciary under the plan (except one under a multiemployer plan) and any insurance contractor for the plan jointly and severally liable for actual damages to any participant, beneficiary, employer, employee organization, or plan aggrieved by such failure or violation of the plan or ERISA title I with respect to plan administration in connection with such claim or its processing. Authorizes the court to assess punitive or exemplary damages in cases where such failure or violation constitutes fraud. Provides that such recovery of damages shall be in addition to other remedies under ERISA title I enforcement provisions. Authorizes civil actions by employers, employee organizations, and plans for relief against insurance contractors or fiduciaries that violate benefits claims procedural requirements.

Revises ERISA title I enforcement provisions to provide for actions: (1) for violations of statutory requirements under title I; and (2) by plans against fiduciaries.

Requires that reasonable attorney's fees and other costs of the action to be paid to the plan participant or beneficiary by the opposing party in any action or settlement proceeding under ERISA title I in which the participant or beneficiary prevails or substantially prevails.

Declares that ERISA does not preempt State laws that provide for: (1) establishing or maintaining any program making available to participants and beneficiaries ongoing assistance in the resolution of claims under group health plans; or (2) licensing or regulating insurance contractors, or sanctions against insurance contractors for unfair claims settlement practices.

Directs the Secretary of Labor to: (1) study the effects of ERISA preemption of State laws relating to employee benefit plans; and (2) report the results of specified congressional committees, with recommendations for legislative reforms.