5th Circuit: Plan's Terms Regarding Preauthorizations Are Ambiguous

NEW ORLEANS - A health insurer abused its discretion under the Employee Retirement Income Security Act by denying benefits for medical coverage provided by an out-of-network provider where the plan terms were ambiguous as to when preauthorization was required and the language of the plan and the summary plan description (SPD) were identical, the Fifth Circuit U.S. Court of Appeals ruled May 31 in an unpublished opinion (Nancy Koehler v. Aetna Health Inc., No. 11-10458, 5th Cir.; 2012 U.S. App. LEXIS 11190). Full story on lexis.com