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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 23 attorneys engaged exclusively in employee benefits, estate planning and employment law. Seven 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

 

 

 

 

March 6, 2014

 

 State and Federal Law Alert

 

 

 

SPD Does Not Trump Terms of Group

Health Plan

 

 

 

The United States Court of Appeals for the Tenth Circuit was recently asked to review whether a summary plan description ("SPD") should be enforced when it conflicts with the terms of a group health plan. In deciding Garrett v. Principal Life Insurance Company, the Tenth Circuit held that the terms of the SPD are not enforceable.

 

In Garrett, the plaintiff was insured through a group medical benefits policy which was part of an ERISA-covered employee benefits plan. Along with the group policy, the insurer provided "Policyholder Booklet-Certificates" which served as the plan's SPD and described the basic features of the coverage.

 

The 2007 group policy provided coverage for inpatient hospital alcohol abuse treatment. In 2008, the insurer issued a new Booklet-Certificate which excluded inpatient treatment for alcohol abuse, but the group policy was never amended to exclude such coverage.

 

In 2009, the plaintiff received inpatient alcohol abuse treatment, and the insurer denied coverage for the treatment. The plaintiff appealed the claim denial and when the insurer upheld its denial, he sued in federal district court to challenge the insurer's denial of benefits.

 

The insurer asserted that the 2008 Booklet-Certificate should control what is a covered medical benefit under the plan because the plaintiff received a copy of the 2008 Policyholder Certificate which contained the exclusion for inpatient alcohol abuse treatment. The district court disagreed with the insurer, finding that the 2007 group policy was controlling and not the 2008 Booklet-Certificate. The insurer then appealed to the Tenth Circuit.

 

After reviewing the facts of the case, the Tenth Circuit upheld the district court's decision. The Court noted that the terms of an SPD cannot be enforced over the terms of the plan, and that the 2007 group policy was the governing plan document. Consequently, the Court ruled that the 2007 policy provided coverage for inpatient alcohol abuse treatment and ordered the insurer to pay the plaintiff's claim.

 

 

 

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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.