There were several recent court decisions that have addressed the right of medical providers, acting under assignments of ERISA plan benefits from patients, to seek plan documents and summary plan descriptions, and to sue plan fiduciaries.
In one case, the district court dismissed the action, holding that the patients had not assigned their rights to sue the plan for statutory penalties. The provider attempted to obtain a retroactive assignment, but the Eleventh Circuit court of appeals held that the provider was not a participant nor a beneficiary in the plan and thus had no standing to bring a claim.
In another suit, the claims administrator denied access to information requested by the provider. The provider sued a self-insured health plan’s claims administrator, alleging underpaid benefits and breach of fiduciary duty. The court held that the claims administrator was not the plan administrator, and thus the claims administrator was within its rights to deny the provider’s request. The court allowed the fiduciary claim to continue so that all parties can make their arguments and the court can decide whether the plan participant’s rights to benefits were assigned to the provider.
Various courts have held that anti-assignment clauses in ERISA plan documents are enforceable, which can prohibit providers from requesting information or bringing a claim against a health plan.
Accordingly, health plans and employers that sponsor health plans should be sure to review and incorporate strong anti-assignment language to prevent third parties from bringing lawsuits against the plan. It is possible that the anti-assignment can be waived depending on the actions of the parties. Thus, in addition to the appropriate language, health plan and claims administrators should be careful in dealing with third parties to avoid the argument that the anti-assignment of benefits was waived.