Release Date: 12/ 12/ 2006
What group health plan documents must be provided to a plan participant upon request?
Question: Our company has just received a letter from an employee who is threatening to sue because she feels she was wrongly denied benefits under our group health plan. The letter asks for copies of plan documents. What are our responsibilities?
Answer: If your company fails to provide the required documents, your ability to defend the benefit denial if the matter does end up in court may be weakened. Your company may also receive penalties for non-compliance. Follow the guidelines below to protect your company.
When must the documents be provided?
The health plan administrator is required under federal ERISA law to disclose specified plan documents within 30 days after a written request from the plan participant. For each day these documents are not provided starting 30 days after the written request was made, the courts are authorized to impose penalties of up to $110 per day on the plan administrator.
Which documents must be provided to the plan participant?
- The latest updated summary plan description (including interim summaries of plan modifications).
- The latest annual report (form 5500).
- Any terminal report (final form 5500).
- The bargaining agreement, trust agreement and contract.
- Other instruments under which the plan is established or operated, including:
- Plan documents
- Insurance policies
- Usual and customary fee schedules and guidelines in the possession of the plan administrator
- TPA contracts (if they affect plan administration)
- Minutes of plan meetings (affecting plan administration) and
- Documents required to be supplied automatically (such as COBRA notices).
- Requested documents that the plan administrator does not possess are generally not required to be disclosed.
What documents must be provided to an ERISA benefit claimant who appeals a benefit denial?
The plan participant appealing a benefit denial has a right to request copies of all documents, records, and other information that are relevant to the claim for benefits, including:
- Documents relied on in making the benefit denial.
- Documents submitted, considered, or generated in the course of making the denial.
- Documents demonstrating compliance with administrative safeguards to ensure consistency and adherence to governing plan documents.
How must the documents be provided?
Documents must be furnished using a method "reasonably calculated to ensure actual receipt of the material." This could include mail, hand-delivery, or electronic delivery. The plan administrator may charge the participant for copying not to exceed 25 cents per page, but may not charge for postage and handling or for other tasks associated with the request for documents.
