A recent federal ruling may help injured Humboldt County residents with employer based health plans. Those injured by the negligent acts of others have been facing increasing hurdles in obtaining compensation if they are covered by an employment health insurance plan covered by ERISA. Many employer based plans take the position that the insurer is entitled to recover every dollar paid for health care, even if that position results in the injured party and their attorney receiving nothing. And when injured parties seek to view the actual health plan which purportedly entitles the insurer to put its interests over its insured, the insurers have often refused to provide the actual plan, instead simply offering summary plan descriptions (SPD's).
The U.S. District Court for North Carolina addressed this issue in Strickland v. AT&T Benefit Plan, 2012 WL 4511367 (W.D.N.C.). The court ordered the plan to produce its “plan document,” recognizing that terms of an SPD are not, in and of themselves, enforceable under Cigna v. Amara. Here is what the judge stated: "Finally, the Court notes that Defendant has yet to provide Plaintiff a copy of the actual plan documents, thus precluding Plaintiff from determining whether the SPDs are consistent with the plan documents. See (Doc. No. 24 at 2 n. 1) (“Although Plaintiff's counsel had requested copies of plan documents as far back as August 17, 2007 (AR 0015–16), the full plan document never has been produced.”). The Fourth Circuit explained in McCravy II that, “per Amara, ‘summary documents, important as they are, provide communication with beneficiaries about the plan, but that their statements do not themselves constitute the terms of the plan....’ “ 2012 WL 2589226, at *5 n. 5 (quoting Amara, 131 S .Ct. at 1878); see also Skinner v. Northrop Grumman Retirement Plan B, 673 F.3d 1162 (9th Cir.2012). Thus, Defendant has “not provided evidence suggesting that the actual terms of the plan were ever communicated to [Plaintiff], beyond the SPD.” Israel, 2012 WL 3116544, at *6 n. 11; see also McCravy, 2012 WL 2589226, at *5 n. 5. Defendant is ORDERED to provide Plaintiff with a copy of the relevant plan documents within thirty (30) days of entry of this Order."