Must an ERISA plan reimburse its beneficiaries for the cost of photocopying medical records? Faced with this issue, the Ninth Circuit decided against the beneficiary in Sgro v. Danone Waters of N. Am., Inc., No. 06-55916 (9th Cir. July 2, 2008). The result would presumably be controlling in an ERISA case originating in Hawaii.
Sgro applied for disability benefits from MetLife, the company that made benefit determinations under the employer's ERISA plan. After a dispute on who should pay for copying medical records, Sgro eventually paid $412 for copies submitted to MetLife. Sgro's claim for benefits was then denied.
On appeal, Sgro argued a California insurance regulation required MetLife to reimburse him for the cost of copying the medical records it requested. The Ninth Circuit disagreed because the plan was governed by ERISA, which preempted the California regulation.
Sgro also claimed MetLife violated ERISA's regulation on "claims procedures," 20 C.F.R. 2560.503-1. The regulation prevented an insurer from unduly inhibiting beneficiaries from claiming benefits, including requiring payment of a fee as a condition to making a claim. The Ninth Circuit rejected this argument as well. The copying expenses here were not a "condition" of making his claim. The plan merely required Sgro to provide documentation, which was not the same as conditioning his application on a payment. Nothing in the regulation prohibited MetLife from requiring Sgro to provide, at his own expense, the documents needed to prove his disability.
