Nancy Koehler v. Aetna Health, Inc.
683 F.3d 182
| 5th Cir. | 2012Background
- Koehler seeks ERISA benefits for care obtained outside the HMO; Aetna denied due to lack of preauthorization.
- Referral to Dr. Whitmore was outside the HMO after initial in-network referrals; the service date and amount were May–June 2009, $2,300.
- Aetna’s denial letter cited nonparticipating-provider services require a PCP referral and pre-authorization.
- COC and the plan summary contain ambiguous language about preauthorization for ad hoc outside services; Subsection H (outside referrals) and General Provisions I use different terms.
- The majority finds the plan ambiguous and the plan summary inadequate, raises concerns of bad faith and potential conflict of interest, and remands for further proceedings including exhaustion issues; concurrence disagrees on ambiguity but concurs in remand.
- The decision discusses ERISA standards for abuse of discretion, plan summaries versus plan text under CIGNA v. Amara and related Fifth Circuit precedent; remand to address remaining issues.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Preauthorization ambiguity for ad hoc outside referrals | Koehler argues Subsection H allows ad hoc outside referrals without preauthorization. | Aetna asserts explicit preauthorization exists in Subsection H and I and in exclusions. | Ambiguity exists; not clearly requiring preauthorization. |
| Whether Aetna abused its discretion in denying benefits | Aetna misread plan language and acted in bad faith. | Denial based on a legitimate interpretation of the plan terms. | Evidence supports potential abuse and bad faith; need remand to evaluate more fully. |
| Exhaustion of administrative remedies | KOehler exhausted administrative procedures or should be deemed exhausted due to improper procedures. | Procedures may be insufficient or improperly applied. | Remand for consideration of exhaustion issues. |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (U.S. 1989) (establishes abuse-of-discretion review in ERISA cases)
- Gosselink v. American Tel., Inc., 272 F.3d 722 (5th Cir. 2001) (plan interpretation must have fair reading of the plan)
- CIGNA Corp. v. Amara, 131 S. Ct. 1866 (U.S. 2011) (plan text vs. summary; courts may look outside the plan's written language to determine terms)
- Hansen v. Continental Ins. Co., 940 F.2d 971 (5th Cir. 1991) (plan summaries interpreted in favor of lay understanding; conflicts with plan text treated specially)
- Rhorer v. Raytheon Eng'rs & Constructors, Inc., 181 F.3d 634 (5th Cir. 1999) (ambiguous plan language; duty to interpret consistently with summary terms)