What to do
Work out which document you need
Employer or union plan: Summary Plan Description, and also the full plan document. Insured plan: Evidence of Coverage, sometimes called a certificate of coverage or policy.
Ask the right party
Employer plan: HR or the benefits administrator. Insured plan: the insurer's member services, or the member portal, where it is often a download.
Ask in writing, and ask for the plan document too
For an employer plan, request both the SPD and the governing plan document. Where they disagree, the plan document controls.
Search it for four things
The exclusions list, the definition of medically necessary, the prior-authorization rules, and the appeals section with its deadlines.
Save a copy with the date you received it
Plan terms change annually. The version in force when your claim was denied is the one that governs it.
What you are looking for once you have it
Read the exclusions before anything else. If gender-affirming care is excluded outright, your case is about whether that exclusion is lawful for your plan type. If it is not excluded, your case is about medical necessity. Those are different arguments and the document tells you which one you are in.
Common questions
- Can my employer refuse to give me the plan document?
- For an ERISA plan, no. Participants have a right to plan documents on written request, and there are penalties for unreasonable delay.
- Which version applies to my claim?
- The one in force on the date of service or the date of the denial. Plans change yearly, so note which year's document you are reading.