Fifth Circuit Reverses Summary Judgment in Case for Benefits under a Health Plan

The U.S. Court of Appeals for the Fifth Circuit recently reversed a district court?ÇÖs grant of summary judgment in a case involving a suit to recover health insurance benefits under a health plan governed by ERISA. In the case, the insurer refused to reimburse the plaintiff for care received from a specialist outside of the HMO to whom she had been referred by a physician in the HMO. The insurer denied the claim because the referral was not pre-authorized. The district court held that the insurer did not abuse its discretion in denying coverage. On review, the Fifth Circuit determined that the terms of the plan with respect to pre-authorization requirements were ambiguous and the need for pre-authorization was not clearly stated in the certificate of coverage which served as the plan?ÇÖs summary plan description (?Ç£SPD?Ç¥). Accordingly, the Fifth Circuit held that it could not be held, as a matter of law, that the insurer did not abuse its discretion in denying coverage. This decision reinforces why unambiguous and detailed SPDs are needed. Koehler v. Aetna Health Inc., No. 11-10458 (5th Cir. May 31, 2012).