(Transcribed from the original, received June 25, 1999)

U.S. Department of Labor

Pension and Welfare Benefits Administration 525 S. Griffin Street Federal Building, Room 707 Dallas, Texas 75202-5025 Phone: (214) 767-6831 Fax: (214) 767-1055

June 22, 1999

R. James Martin
501 Sycamore Lane #327
Euless, TX 76039

Dear Mr. Martin:

This letter is in response to your inquiry regarding Metromedia Restaurant Group Health Plan's denial of some of your medical claims for your Lyme Disease treatment.

This office administers many provisions of the Employee Retirement Income Security Act of 1974 (ERISA), which is intended to protect the benefits of employees and retirees in private-sector pension and welfare benefit plans. Under ERISA, a medical plan generally is considered to be a welfare benefit plan.

ERISA does not establish minimum standards governing the circumstances under which benefits are payable under employee welfare benefit plans. ERISA does not require health benefits plans to cover any specified medical benefits or medical services. Therefore, welfare benefit plans are generally free to establish their own rules determining what benefits are offered. If a plan is and ERISA covered plan, the rules of the health benefit plan as adopted by a the plan sponsor determine whether a participant is eligible for particular benefits.

The Department of Labor does not interpret plan documents or determine whether individuals are entitled to benefits. That is the responsibility of the plan administrator or other appropriate plan official. The Department of Labor receives numerous complaints of disputes between plan participants and employers regarding the interpretation of plan documents and factual information. Generally, we must recommend to plan participants that they seek their own legal counsel. Therefore, if you believe your rights under your plan or ERISA have been violated, and you have exhausted the claim and appeal procedures under the plan, you may want to consult legal counsel for further assistance.

I hope this information is helpful to you.

Sincerely,


David Dove
Associate Regional Director