[NM] Does a law firm’s refusal to disclose a plan’s administrative services agreement violate ERISA?

I requested the current plan documents, as well as documents governing the operation of the medical plan, including ASAs and similar contracts, from my employer, the Plan Administrator, under ERISA § 104(b)(4). The law firm handling the request on behalf of the Plan Administrator of this self-funded plan, insists I am not entitled to the ASA and only provided the basic Plan Document and SPD already available on the HR website. However, my understanding is that, since my employer and I are in New Mexico, this would fall under the 10th Circuit jurisdiction, where I believe I am entitled to the ASA and possibly more documents. They insist I am not, and plainly state they will not provide it under ERISA § 104(b)(4).

Yes. They state "You requested insurance contracts and ASAs. Note, these documents are not within the scope of documents that are required to be disclosed under ERISA § 104(b)(4)."

They involved the law firm. I sent a letter with my request via Certified Mail to the address in the Plan Document, for such a request. They had this law firm respond to me, rather than responding directly.

I also requested complete administrative records for all of my claims for which administrative records exist. Those I am not certain I am directly entitled to in this case, but I do have reasons that are more complicated than the request for the ASA, to believe I may be entitled to them, but may be outside the scope of this question regarding the ASA. Seeing the ASA may help me answer some of my outstanding questions in terms of who acts as a fiduciary or should be acting as a fiduciary in this plan. I cannot understand how this plan operates with the information they have given me so far.

My concern is that the SPD suggests fiduciary duties are solely with the TPA / Claims Administrator. The law firm has also stated that the Plan delegates discretionary authority to the TPA. However, I know for a fact, with documentation, that my employer, the Plan Administrator, has overridden claims decisions after exhausting appeals on some claims. This appears to be at minimum a functional fiduciary duty. Since they are withholding the ASA from me, I have no idea whether this additional fiduciary is documented. This adds an issue of the Plan Administrator, at least to some extent, whether documented or not, acting as a fiduciary with a conflict of interest, since they are also the Plan Sponsor in this self-funded plan. My concern is that this is not documented at least in any documents I have been provided.

I was just curious if there are any other considerations at this time. I will add that I requested a HIPAA Right of Access of all PHI at the TPA, and it is obviously incomplete. That is separate from ERISA, but they basically claim to have processed my claims without handling any medical data, which seems implausible. Since there have been provable instances where the Plan Administrator has at minimum overridden TPA claim decisions, it is unclear what possibly undocumented (undocumented in the documents they will provide to me) fiduciary roles the Plan Administrator is possibly taking. Are they the ones processing and maintaining medical data regarding submitted claims? Basically, I need some transparency to understand how the Plan actually works, since the documents seem to be very different from how it really operates.

I am considering such, depending on how they respond to follow up e-mails and letters. Technically, if the ASA is considered disclosable in my jurisdiction, which I believe it is, they are already in violation of not providing it within 30 days. The question is when or if to get an ERISA-specializing attorney involved, I suppose. The question is whether they will provide the other documents I am requesting outside of a suit with discovery, which may end up being what is necessary to understand whether an undocumented conflicted fiduciary role exists.

OK, so is it appropriate for a law firm acting on behalf of the Plan Administrator, to claim otherwise, to withhold the ASA from me? Essentially it raises professional conduct concerns as well.

OK, that was my understanding as well, although I am not sure how that necessarily will fit into the rest of what may end up becoming a suit. It just seems troubling since my understanding is that a law firm working on behalf of the Plan Administrator also has a duty to Plan Participants as well. This is sounding like something to get an ERISA-specific attorney involved in, though, it's just the whole matter of finding one and starting that process.

OK, thank you. I think this is likely as far as any of this can go until another set of correspondence with their law firm occurs and/or retaining an attorney who can review the details in depth.