COBRA, HIPAA, and SPD are a few of the acronyms under ERISA which address issues that arise in relation to the rights and duties of beneficiaries and participants, and employers, insurers and benefit plan administrators regarding health insurance.

COBRA, Consolidated Omnibus Budget Reconciliation Act, is the law which requires that beneficiaries under a employer provided health insurance plan be provided notice of their right to continue coverage. The extended coverage period is 18 months from the end of health benefits upon termination of employment (including resignation) and 36 months from divorce or legal separation of the covered employee from the employee’s spouse. There are other extensions available in the event of death or SSA disability of the covered employee. Notice of rights to continue coverage, which must explain the premium amount, the election deadline and the duration of coverage, must be provided within 44 days of the qualifying event, termination of employment or divorce.

HIPAA, Health Insurance Portability and Accountability Act, is a law which provides various duties to health insurers and health service providers. The most practical application of this law is the provision that one who was an insured under a group health insurance plan for at least a year will not be subject to a pre-existing condition exclusion provided they obtain group coverage within 63 days of the end of their prior coverage. For purposes of considering whether one has met the required coverage period and not had their insurance lapse for greater than 63 days insurance obtained under COBRA is considered.

SPD, Summary Plan Description, is a required written document which is required to contain an intelligible description of all circumstances which may result in disqualification, ineligibility, or denial or loss of benefits. An employee benefits handbook may not satisfy the requirements of ERISA depending on its contents. An SPD must be provided within 90 days of commencement of benefit coverage and must contain COBRA rights information. Further, an SPD must be provided to a participant or beneficiary who requests an SPD in writing to the plan administrator. Civil penalties of up to $110.00 per day may be assessed for failure to provide the required information.

In addition to COBRA, HIPAA, and SPD a beneficiary has a right to challenge a denial of a claim for health benefits. First, a denial must be appealed to the appeal entity provided for in the plan. Thereafter, a formal lawsuit in federal court is available to address ERISA issues.

If you have any questions or concerns on the issues of health insurance and ERISA please contact Bogin, Munns & Munns at 407-578-1334.