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The Wagner Law Group Description 

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established in 1996, The Wagner Law Group has 22 attorneys engaged exclusively in employee benefits, estate planning and employment law. Six of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.

 

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Florida Office 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

San Francisco Office

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104

 

www.wagnerlawgroup.com

 

 

 

 

April 30, 2015

 

 Health and Welfare Law Alert

 

 

 

SPD Alone Cannot Grant Plan Administrator Discretionary Authority to Determine Eligibility for Benefits

 

 

 

The United States Court of Appeals for the Ninth Circuit has ruled, in Prichard v. Metropolitan Life Insurance Company, that a summary plan description ("SPD") cannot give a plan administrator discretionary authority to review a claim when the formal plan document is silent on the matter. Therefore, a court does not have to defer to the plan administrator's decision.

 

Background. The plaintiff was covered under his employer's LTD plan. After initially approving the plaintiff's claim for LTD benefits, the insurer determined that the benefits would be limited to 24 months under a restriction applicable to mental or nervous disorders. The plaintiff made a claim for continued benefits beyond the initial 24-month limit, which the insurer denied. After several unsuccessful appeals, the plaintiff sued the insurer in federal district court.

 

District Court. At trial, the parties disagreed on what standard of review the district court should apply to the insurer's decision to terminate benefits. The insurer asserted that the discretionary language contained in the SPD required the court to apply the "deferential abuse of discretion" standard, meaning that the plan administrator's decision would be upheld unless it was "arbitrary and capricious." Conversely, the participant argued that the Supreme Court's prior decision in CIGNA v. Amara required the court to review the matter de novo and, therefore, without consideration of or deference to the plan administrator's decision. (In Amara, the Court held that the terms of an SPD cannot be enforced as the terms of the plan itself.) The insurer responded that the SPD is the only formal plan document and, therefore, its terms warrant discretionary review.

 

The district court concluded that the SPD was the controlling plan document and that it granted the insurer discretionary authority to determine benefits eligibility. Thus, the district court applied the abuse of discretion standard of review and upheld the insurer's decision to terminate the plaintiff's benefits. The plaintiff appealed this decision to the Ninth Circuit.

 

Ninth Circuit. The Ninth Circuit determined that the district court should have used the de novo review standard and rejected the insurer's argument that the SPD was the only formal plan document. Instead, the Ninth Circuit found that the relevant insurance certificate provided that the plan consisted of the group policy and the employer's application. In other words, the insurance certificate identified these documents, and not the SPD, as the entire agreement between the employer and insurer.

 

As a result, the Ninth Circuit concluded that the district court erred when it found that the LTD plan's SPD, rather than the insurance certificate, was the plan document. Because the official insurance certificate contained no discretion-granting language, the Ninth Circuit remanded the matter to the district court to review the insurer's decision de novo.

 

Impacton Employers. The standard of review that a court uses to determine a litigated benefits dispute significantly impacts whether the plan's decision will stand. In fact, it is much less likely that a plan's determination will be upheld when a court applies the de novo standard of review.

 

Employers with insured health plan arrangements are advised to have their wrap plan documents, group policies and insurance certificates reviewed by qualified benefits counsel to determine if those documents properly provide plan administrators with discretionary authority to administer and interpret the terms of their plans. Otherwise, they may discover, as in Prichard, that the governing documents do not contain language sufficient to grant discretionary authority to the plan administrator to determine benefits eligibility. 

 

 

 

 

 

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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.