The Wagner Law Group Description
Wagner Law Group, A Professional Corporation, is a nationally
recognized ERISA & employee benefits, estate planning,
employment, labor & human resources practice.
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.
Wagner Law Group
Fax: (561) 293-3591
7108 Fairway Drive
Palm Beach Gardens, FL 33418
Francisco, CA 94104
March 6, 2014
State and Federal Law
SPD Does Not
Trump Terms of Group
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.
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.
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.
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.
This Newsletter is protected by copyright. Material
appearing herein may be reproduced with appropriate credit.
Pursuant to Internal Revenue Service Circular 230, we
hereby inform you that any advice set forth herein with respect to US
federal tax issues is not intended or written by The Wagner Law Group
to be used and cannot be used, by you or any taxpayer, for the purpose
of avoiding penalties that may be imposed on you or any other person
under the Internal Revenue Code.
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