Joining other circuit courts, the Eighth Circuit has held that a health plan's summary plan description (SPD) was the plan's written instrument for ERISA purposes because it was the only document providing benefits (MBI Energy Servs. v. Hoch, (8th Cir. July 3, 2019)). As a result, a reimbursement provision in the SPD was enforceable against a plan participant who received benefits under the plan after an accident and later secured a settlement from a third party.

The defendant in this case, a covered participant under his employer's self-funded health plan, was injured in an accident and received more than $68,000 in medical benefits from the plan. The participant later reached a settlement with the third party responsible for his injury and was compensated by the third party's insurer. Because the participant was compensated twice for the same injury, the employer sued the participant for reimbursement of the benefits paid on his behalf, with an offset for attorney's fees incurred by the participant in obtaining his settlement. In doing so, the employer relied on a reimbursement provision disclosed to the participant in the plan's SPD (see Standard Clause, SPD Language, Subrogation and Reimbursement). No written instrument (as required under ERISA) was clearly identified as the formal plan document.

The participant asserted that the reimbursement provision was not binding because it was not part of the health plan's formal plan document. A district court ruled in the employer's favor, however, and the participant appealed (see ERISA Litigation Toolkit).

Affirming the district court, the Eighth Circuit concluded that the plan authorized the employer to be reimbursed after the participant's settlement recovery. In considering whether the SPD's reimbursement provision was enforceable, the Eighth Circuit addressed a 2007 decision in which it rejected the argument that an SPD cannot also serve as the plan. In the 2007 case, which also involved a plan reimbursement dispute, a district court had determined that a reimbursement provision found only in an SPD was not binding. The Eighth Circuit reversed, however, concluding that if no other source of benefits exists, the SPD – regardless of its label – is the formal plan document.

The participant in the current case argued that the Eighth Circuit's 2007 decision was inconsistent with an intervening Supreme Court decision (Cigna Corp. v. Amara, 563 U.S. 421 (2011)) holding that the terms of an SPD are not part of the plan itself (see Article, Expert Q&A on the Impact of CIGNA Corp. v. Amara). The Eighth Circuit acknowledged that Amara undercut aspects of its 2007 decision. However, the Eighth Circuit reasoned that Amara did not address the specific issue in its 2007 decision – that is, whether an SPD can constitute the plan in the absence of any other plan document providing benefits. The Eighth Circuit therefore distinguished Amara (where there was both a plan document and an SPD) from the present case (in which the SPD was the only plan document that provided benefits). The Eighth Circuit concluded that its 2007 decision remained binding law in the Eighth Circuit. Applying the 2007 decision, the Eighth Circuit held that the SPD was the plan's written instrument for ERISA purposes because it was the only document that provided benefits.

The Eighth Circuit observed that other circuit courts have also concluded that Amara did not prevent an SPD from serving as the plan in the absence of a formal plan document. Those other circuit decisions include:

It's not uncommon for an ERISA health plan to be established under a single document that functions as the plan's SPD – perhaps, as here, in coordination with an ASA. In the litigation context, that practice gives participants a strong basis to challenge the enforceability of provisions that can be found only in the SPD. And as the Eighth Circuit acknowledges here, conflating the plan and SPD requirements may also undermine an SPD's ability to function as the clear, simple communication envisioned under Amara. Nonetheless, the "equities" in this case (that is, not allowing a participant to claim benefits without also honoring the plan's reimbursement requirements) were sufficient to win the day for this employer.