Ask for your plan documents
A written request to your employer plan's administrator for the summary plan description and the documents that set the plan's rules, so you can check the denial against them.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this for a plan you get through an employer or union that is covered by the Employee Retirement Income Security Act (ERISA). Address it to the plan administrator named in your plan booklet; if none is named, that is usually the employer. ERISA does not cover government or church plans that have not chosen it, so the legal basis below may not apply, but you can still ask.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan administrator]
Re: Ask for your plan documents Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am a participant in the health plan offered through [Your employer or union], member ID [Member ID]. I am writing to the plan administrator. [Name of the health plan] denied my claim [Claim or reference number] for [The care or drug that was denied] on [Date on the denial notice]. I need the documents that set the plan's rules so I can check that decision against them.
Under section 104(b)(4) of the Employee Retirement Income Security Act (ERISA), please send me copies of:
1. The latest summary plan description, including its description of the claims and appeal procedures and time limits. 2. The latest annual report. 3. The "bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated," including the plan document and any insurance contract with a company that pays or processes claims. 4. Any amendment to these documents that was in effect on [Date of the care].
Please also tell me in writing whether the plan pays claims from its own funds (self-funded) or buys insurance, and the name of the company that processes its claims.
I understand the plan may charge a reasonable copying fee of no more than 25 cents per page. If you will charge for copies, please tell me the amount first.
Please mail the documents within 30 days of the date of this letter, which is the period that ERISA section 502(c)(1) uses for requests like this one. Please send them [How you want to receive the documents], and confirm in writing the date you received this request so that I have proof of delivery.
Enclosures: 1. Copy of the denial letter 2. Copy of your member card (front and back)
Sincerely, [Your name]
Before you send it
Send it to the plan administrator named in your summary plan description. If no administrator is named, send it to your employer's human resources department and mark it for the plan administrator; the plan sponsor is the fallback. Do not guess an address: use the one in your plan booklet or ask human resources. To prove it arrived, send it by certified mail with a return receipt, or hand a copy to human resources and ask them to date-stamp yours, and keep a copy.
What to enclose
- Copy of the denial letter
- Copy of your member card (front and back)
What happens next
- You: send the letter and keep the proof of delivery. The date the administrator receives it starts the 30-day period.
- You: write day 30 on your calendar. ERISA lets a court, at its discretion, penalize a plan administrator who does not mail required information within 30 days of a request; the amount is set in a federal regulation, up to $110 a day. A court decides this, not the plan or an agency, and it applies to the administrator, not to the insurer that processes claims.
- You: do not let this request delay your appeal. For most job-based plans you have at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls.
- You: when the documents arrive, look for the claims and appeal section, the definition of medical necessity and any exclusion the plan relied on. If the documents do not arrive, tell the United States Department of Labor, Employee Benefits Security Administration, at 1-866-444-3272.