SPD Overrides Enrollment Guide, Judge Rules

September 26, 2002 (PLANSPONSOR.com) - A stroke victim isn't entitled to an unlimited amount of physical therapy paid by her retired husband's former employer if such coverage isn't called for in the company's benefit summary plan description (SPD), a court ruled.

US District Judge F.A. Little Jr. of the US District Court for the Western District of Louisiana ruled that the administrator of the CaseNewHolland Inc., health plan correctly argued that Bailey was relying on the wrong plan document in her battle to get the therapy covered, according to BNA.

The Louisiana company’s SPD limited physical therapy to 60 visits annually, the administrator argued.

According to Little, Bailey instead relied on the plan’s enrollment guide, which didn’t spell out any therapy limitation in the CNH Health and Welfare plan.

With a conflict between the enrollment guide and the SPD, the SPD governs, the judge said.

Bailey received daily physical therapy after her August 2000 stroke until she was told in March 2001 about the 60 annual visit limit. She then sued the insurance company.

Little ruled that the enrollment guide didn’t qualify as an SPD because it didn’t contain certain information such as the plan administration, eligibility requirements, circumstances resulting in disqualification or loss of benefits, or procedures for presenting claims. So the guide didn’t have any binding effect on the plan administrator, Little said.

The case is Bailey v. Cigna Insurance Co., W.D. La., No. 01-1115 Section “M,” 9/5/02.