In the case Bailey v. CIGNA Insurance Co., the appeals court affirmed a lower court’s decision that although the enrollment guide provided information about a plan, it was not an SPD because it did not contain any of the information required in an SPD by the Employee Retirement Income Security Act (ERISA) such as information regarding plan administration, eligibility requirements, circumstances resulting in disqualification or loss of benefits, or procedures for presenting claims.
Health care plan participant Linda Bailey and her husband John sued CIGNA, the plan administrator, after the company refused her more physical therapy sessions after she had been going for three months. CIGNA maintained that the SPD limited physical therapy coverage to 60 visits per year. However, the Baileys said that in the enrollment guide, which they used that as their SPD, there was no limit on physical therapy sessions.
Therefore, although the law states that “clear and unambiguous statements in the [SPD] are binding,” because the enrollment guide referred to by the Baileys was not an SPD, CIGNA is not required to follow statements in the enrollment guide, the judges said.
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