When Nancy Koehler discovered there was no participating provider who could supply a medically necessary dental device, she obtained a referral to an out-of-network specialist, as permitted by her plan. Aetna later denied coverage on the grounds that the referring physician failed to obtain pre-authorization for the referral. Koehler filed suit for benefits pursuant to ERISA § 502(a)(1)(B), and the District Court granted summary judgment to Aetna.
In Koehler v. Aetna Health Inc., the Fifth Circuit Court of Appeals reversed and remanded, holding that the certificate of coverage does not unambiguously require pre-authorization by the insurer, especially compared to other clearer provisions. The court also noted the certificate’s assurance that Aetna would “not use any decision making process that operates to deny Medically Necessary care that is a Covered Benefit,” and held that it “seems to disavow relying on a harmless procedural lapse as a basis for refusing” otherwise covered services.
The court also noted that while the plan gives Aetna discretion to resolve ambiguities in its favor, ambiguities in the summary plan description must be resolved in favor of the beneficiary. Since Aetna had conceded earlier in the litigation that the text in the certificate of coverage constitutes the summary plan description, the identical language was subject to two different interpretive standards. And although the Supreme Court’s decision in CIGNA Corp. v. Amara requires that the terms of a plan control over those of the summary, ambiguous plan language should be “given a meaning as close as possible to what is said in the plan summary.”