Text: H.R.6147 — 102nd Congress (1991-1992)All Information (Except Text)

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HR 6147 IH
102d CONGRESS
2d Session
 H. R. 6147
To amend title I of the Employee Retirement Income Security Act of 1974 to
provide that unreasonable discrimination in benefits under group health plans
affecting benefit claims thereunder constitutes interference with rights
protected under such Act and to provide for effective remedies therefor,
and to provide for adequate notice of material changes to group health plans.
IN THE HOUSE OF REPRESENTATIVES
October 5, 1992
Mr. HUGHES (for himself and Mr. BOEHLERT) introduced the following bill;
which was referred to the Committee on Education and Labor
A BILL
To amend title I of the Employee Retirement Income Security Act of 1974 to
provide that unreasonable discrimination in benefits under group health plans
affecting benefit claims thereunder constitutes interference with rights
protected under such Act and to provide for effective remedies therefor,
and to provide for adequate notice of material changes to group health plans.
  Be it enacted by the Senate and House of Representatives of the United
  States of America in Congress assembled,
SECTION 1. SHORT TITLE.
  This Act may be cited as the `Group Health Plan Nondiscrimination Act
  of 1992'.
SEC. 2. PROTECTION FROM INTERFERENCE WITH RIGHTS.
  Section 510 of the Employee Retirement Income Security Act of 1974 (29
  U.S.C. 1140) is amended--
  (1) by inserting `(a) IN GENERAL- ' after `SEC. 510.'; and
  (2) by adding at the end the following new subsection:
  `(b) DISCRIMINATION BASED ON BENEFIT CLAIMS UNDER GROUP HEALTH PLANS-
  `(1) IN GENERAL- In any case in which a plan sponsor adopts a change in
  group health plan coverage, the adoption of such change shall be deemed
  a form of discrimination prohibited under subsection (a) if--
  `(A) the adoption of such change occurs after submission of a claim under
  a group health plan maintained by the plan sponsor for provision of, or
  reimbursement for, a course of treatment which was medically necessary, and
  `(B) after such change takes effect, the value of benefits provided to the
  claimant under the group health plan coverage in the form of provision of,
  or reimbursement for, such course of treatment is reduced or eliminated.
  `(2) EXCEPTIONS- Paragraph (1) shall not apply with respect to any claimant
  in the case of the adoption of any change in group health plan coverage if--
  `(A) the plan is unable to pay benefits when due, and, but for the adoption
  of such change, will be terminated, and
  `(B) there is no reasonable, nondiscriminatory alternative change within
  the plan sponsor's control.
  `(3) GROUP HEALTH PLAN- For purposes of this subsection, the term `group
  health plan' has the meaning provided in section 607(1).
SEC. 3. LEGAL RELIEF FROM DAMAGES FOR INTERFERENCE WITH RIGHTS UNDER PLAN.
  (a) DAMAGES- Section 502(c) of the Employee Retirement Income Security Act
  of 1974 (29 U.S.C. 1132(c)) is amended by adding at the end the following
  new paragraph:
  `(4)(A) Any person who violates section 510 with respect to any participant
  or beneficiary under a group health plan shall be liable to such participant
  or beneficiary for actual damages (including compensatory and consequential
  damages proximately caused by the violation), except that, subject to
  subparagraph (B), damages for such violation shall not include punitive
  damages.
  `(B) In any case in which the violation constitutes willful, fraudulent,
  or malicious conduct, bad faith, or gross negligence, each person liable
  under subparagraph (A) may, in the court's discretion, be liable to the
  such participant or beneficiary for exemplary damages equal to not more
  than the greater of--
  `(i) 100 percent of the amount of actual damages awarded, or
  `(ii) $10,000.
  `(C) For purposes of this paragraph, the term `group health plan' has the
  meaning provided in section 607(1).'.
  (b) ATTORNEY'S FEES- Section 502(g) of such Act (29 U.S.C. 1132(g)) is
  amended by adding at the end the following new paragraph:
  `(3) In any action for damages under subsection (c)(4) in which the
  plaintiff prevails or substantially prevails, the court shall award the
  plaintiff reasonable attorney's fees and other costs of the action, including
  reasonable expert witness fees and costs, to be paid by the defendant. Fees
  awarded under this paragraph shall be at generally prevailing hourly rates.'.
SEC. 4. REPORTING AND DISCLOSURE REQUIREMENTS.
  Section 101 of the Employee Retirement Income Security Act of 1974 (29
  U.S.C. 1021) is amended--
  (1) by redesignating subsection (f) as subsection (g); and
  (2) by inserting after subsection (e) the following new subsection:
  `(f) NOTICE OF MATERIAL CHANGES IN TERMS OF GROUP HEALTH PLANS-
  `(1) IN GENERAL- A group health plan shall issue to each participant and
  beneficiary, in language calculated to be easily understood by the typical
  participant or beneficiary, a notice of any material change in the terms
  of the plan.
  `(2) TIME FOR DISCLOSURE- The notice referred to in paragraph (1) shall be
  issued to each participant and beneficiary not later than 10 days before
  the adoption of the material change involved. Any material change may not
  take effect until 60 days after the issuance of such notice.
  `(3) SPECIAL REQUIREMENTS FOR SELF-INSURED PLANS- In the case of a
  self-insured group health plan, any notice issued pursuant to this section
  shall include a statement--
  `(A) indicating that the plan is a self-insured health plan and is not a
  policy of insurance,
  `(B) indicating that the plan is not subject to State guarantee fund
  protection,
  `(C) identifying the person who is responsible for claim determinations
  and processing, and
  `(D) indicating that, if the plan does not pay all benefits for which
  participants or beneficiaries are eligible under the plan, responsibility
  for payment for medical care may to some extent remain with the participant
  or beneficiary.
  `(4) DEFINITIONS- For purposes of this subsection--
  `(A) GROUP HEALTH PLAN- The term `group health plan' has the meaning
  provided in section 607(1).
  `(B) SELF-INSURED PLANS- A group health plan is `self-insured' unless all
  benefits provided under the plan are provided under a contract or policy of
  insurance issued by a person licensed by a State to engage in the business
  of insurance.'.
SEC. 5. EFFECTIVE DATE.
  The amendments made by this Act shall apply with respect to changes in
  group health plan coverage adopted on or after the date of the enactment
  of this Act.