How to get your plan documents

If you get coverage through a private employer, the law lets you ask the plan administrator, in writing, for the documents that set your plan’s rules. The most useful is the summary plan description. It tells you what the plan covers, how claims are decided and how long you have to appeal. Ask for it in writing, keep proof, and read it for the sections that apply to your denial.

What this means

A plan has more than one document. The claim file shows what the plan did with your claim. The plan documents show the rules it was supposed to follow. You need both.

The summary plan description is the plan’s plain-language booklet of its terms. For a job-based plan it must describe the claims and appeal procedures and their time limits. Where an insurance company is involved in a group health plan, it must also say whether, and how far, benefits are guaranteed by an insurance contract, and what services the insurer provides, such as paying claims. That is one way to learn whether your employer pays claims from its own money (a self-funded plan) or buys insurance.

On a written request, the plan administrator must give you:

• the latest summary plan description;
• the latest annual report; and
• any “bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated”.

The administrator may charge a reasonable fee for copies, no more than 25 cents per page. The administrator is the person or body named in the plan document. If none is named, it is the plan sponsor, usually your employer.

What to do

1. Check what you already have (your step). Look for a benefits booklet from when you enrolled, or the plan’s documents in your employer’s benefits portal. Your insurer may call it a certificate of coverage or a member handbook. A Summary of Benefits and Coverage is a short summary, not the full plan, so ask for the longer document too.
2. Find the administrator. The summary plan description names the plan administrator. If you do not have one, ask your employer’s human resources department who the plan administrator is. Do not guess an address.
3. Write the request. Use the plan documents request letter. Ask for the latest summary plan description, the latest annual report, the plan document and any insurance contract, and any amendment in effect on your date of service. Ask the administrator to say in writing whether the plan is self-funded or insured and who processes claims.
4. Send it so you can prove it arrived. Use certified mail with a return receipt, or hand a copy to human resources and ask them to date-stamp yours. Keep a copy.
5. Mark day 30 on your calendar. See the timing section below.
6. Read the sections that matter. Look for the claims and appeals section, the definition of medical necessity, the exclusions and limits, and any time limit for filing claims or lawsuits. Then see using your plan’s own words.
7. Do not wait to appeal. You have at least 180 days after you receive the denial notice, and your plan may allow more. Check the date on your notice, which controls.

How long the administrator has to answer

An administrator who fails or refuses to mail required information within 30 days of your request “may in the court’s discretion be personally liable” for up to $110 a day. Three limits matter:

• Only a court can award the penalty. The plan, the insurer and the government cannot.
• It is discretionary, so a court may award nothing.
• It applies to the administrator, and only to coverage under the Employee Retirement Income Security Act (ERISA), the federal law for private employer plans. It does not apply to other coverage.

Treat 30 days as the date to follow up, not as money you are owed.

What the plan may say, and what to say back

“Here is your benefits summary.” Thank them, then ask in writing for the full summary plan description and the plan document. A short summary does not replace them.

“Ask the insurance company.” The law puts the duty on the plan administrator. The insurer that processes claims may not be the administrator. Ask who is, and address your request to that person.

“We do not have to give you that.” Quote the right in your reply. If a private employer plan still refuses, you can call the United States Department of Labor, Employee Benefits Security Administration, at 1-866-444-3272.

The rule

On written request, an ERISA plan administrator must furnish the latest summary plan description, the latest annual report and the instruments under which the plan is established or operated, and may charge no more than 25 cents per page for copies. See section 104(b)(4) of ERISA, which is section 1024(b)(4) of Title 29 of the United States Code, and section 2520.104b-30 of Title 29 of the Code of Federal Regulations (29 CFR 2520.104b-30).

Watch for

• Plans outside ERISA. ERISA does not cover government plans (federal, state, local or school district) or church plans that have not chosen ERISA coverage, so this particular right does not apply to them. Ask your human resources department anyway, and check your plan’s own rules and your state’s law.
• Plans you buy yourself. An individual or marketplace policy is a contract with an insurer. Ask the insurer in writing for the full policy and any changes. This site has not found a federal right to it that matches the one above.
• Which version applies. Plans change. Ask for any amendment in effect on your date of service.
• The Form 5500. The Department of Labor runs a public search of plans’ annual reports at efast.dol.gov/5500Search. A plan with fewer than 100 participants that is unfunded, insured, or both does not have to file, so finding nothing does not prove how a plan is funded.

What next

• How to request your claim file: the plan’s papers about your claim.
• Using your plan’s own words: turn the plan’s definitions and exclusions into your arguments.
• Self-funded or fully insured: what the answer in your plan documents changes.
• How to find the insurer’s medical policy: the clinical rule behind a medical necessity denial.