Participant's access to information in claims adjudications.


One of the purposes of ERISA was to provide participants with access to information so they could understand their rights and obtain their benefits from their plans.

One of the major problems that plaintiffs face is obtaining information and documents from insurance companies and third party administrators, when they do not comply with the US Department of Labor Claims regulations. For example, they do not provide the appropriate notices to the claimant about the specific sections they are relying upon in the plan documents or produce the documents relied upon in the claims adjudications.

These entities are not subject to penalties under ERISA unless they are designated as plan administrators, which rarely happens, and they can ignore their obligations to comply with ERISA.

I suggest that the statute and/or the claims regulations be amended to address these issues so that the insurance companies and TPAs will now have a financial incentive to comply with their obligations to the plans and the participants.