In Bd. of Trustees v. Moore, the US Court of Appeals for the Sixth Circuit held that a health plan summary plan description (SPD) governed a subrogation dispute involving a covered plan beneficiary, where no separate formal plan document existed (No. 14-4048, , *1 (6th Cir. Aug. 25, 2015)).

The trustees of the ERISA multiemployer health plan in this case sued a covered plan beneficiary for reimbursement of medical expenses the plan had paid on the beneficiary's behalf when he was injured in a car accident. The litigation arose after the beneficiary:

Although the governing trust agreement between the trustees and participating employers authorized the trustees to adopt and administer a health plan, the trustees had failed to do so. Instead, the trustees had approved an SPD that, according to a plan representative, served as both the plan document envisioned in the trust agreement and the SPD (see Summary Plan Description (SPD) Toolkit). In district court, the beneficiary argued that a subrogation and reimbursement provision in the SPD was unenforceable because it appeared only in the SPD and not in the trust agreement (see Standard Clause, SPD Language, Subrogation and Reimbursement). The district court rejected this argument and granted summary judgment in the trustees' favor on the subrogation claim, holding that:

On appeal to the Sixth Circuit, the parties disagreed regarding whether the SPD (the only document that contained a subrogation provision) was a binding plan document that set out enforceable terms.

Affirming the district court, the Sixth Circuit concluded that the SPD's subrogation provision was enforceable. According to the Sixth Circuit, the district court's reasoning and decision were not in conflict with the Supreme Court's ruling in CIGNA Corp. v. Amara, which held that if SPD language conflicts with the language in the plan document, the plan document controls (131 S.Ct. 1866 (2011)) (see Article, Expert Q&A on the Impact of CIGNA Corp. v. Amara). The Sixth Circuit noted that in Amara it was clear that one document was the plan, a different document functioned as the SPD, and that the two documents were in conflict. In this case, by contrast, the SPD was the only document other than the trust agreement, and while the SPD addressed the details of plan eligibility, payment of benefits and other issues, those details were "entirely missing" from the trust agreement. The court added that Amara did not prevent a document from acting as both the plan document and the SPD. As a result, the Sixth Circuit concluded that:

The court noted that other circuits had addressed the same SPD at issue in this case (in unreported decisions) and had recognized that the SPD functioned as the controlling ERISA plan in the absence of a separate plan document (see Bd. of Trustees of the Nat'l Elevator Indus. Health Ben. Plan v. Montanile, 593 F. App'x 903, 910 (11th Cir. 2014) and Bd. of Trustees of the Nat'l Elevator Indus. Health Ben. Plan v. McLaughlin, 590 F. App'x 154 (3d Cir. 2014)).

This case is a reminder that, notwithstanding Amara, there are circumstances when the parties to a litigated ERISA dispute should expect a court to enforce an SPD's terms over other purported plan documents. Here, the Sixth Circuit had little difficulty distinguishing Amara, based on the contrasting plan documentation in the two cases. As the court appears to acknowledge, it is not uncommon (particularly in the health plan context) for a plan to be established and maintained without both a formal plan document and an SPD. If, as in this case, the plan's administrators intend for the same document to serve as both the plan and SPD (an arrangement that would seem to be disfavored under Amara), that document should satisfy ERISA's requirements for both plan documents and SPDs.