The SPD makes it clear in the introduction that together with the certificate of individual cover, it forms “[the] group insurance certificate”, that it is “part of the group policy” and that “all benefits are subject in all respects to the entire group policy, to which the SPD also belongs”. Aplee. Supp.App. 6. Almost identical wording is found in the certificate of coverage.   Aplee. Supp.App. 7. Although Mr.

S. maintains that he does not have access to the government plan documents and that he cannot determine whether these government documents contradict an existing power of attorney in the SPD, Aplee. Br. 37-38, he did not request a copy of these documents either during the administrative appeal proceedings or at the time of discovery.   Nor did he ask the District Court to defer the decision on the incidental applications for summary judgment so that he could obtain such documents.   Meanwhile, counsel for Horizon argued at the hearing that the only plan document that is not available in evidence has no bearing on Horizon`s discretion and is not relevant to this case.2 Thus, the SPD – which contains the wording of the plan – is sufficient for our consideration.  In Glenn, the Supreme Court recognized that there is a conflict when an employer funds its own benefit plan and that it can exist even when an employer hires an insurance company to administer such a plan.  Glenn, 554 U.S. at 112–14, 128 S.Ct. 2343.   However, Glenn did not argue that insurance companies necessarily suffer from conflicts of interest when hired by plan sponsors.  Instead, the court said an employer`s dispute can extend “to the selection of an insurance company” as the plan`s administrator.

 Id. at 114, 128 p.ct. 2343 (emphasis added).   While we assume that this employer dispute extends to Horizon, Glenn, as an insurer, has not addressed a situation where an insurer delegates its authority to review claims to an independent external plan administrator.   Such delegation may mitigate a dual conflict of interest.  Finley v. Hewlett-Packard Co. Empl. Benefits Org.

Income Prot. Plan, 379 F.3d 1168, 1176 (10th Cir.2004).   Claiming a conflict on the basis of a general economic incentive, such as attracting more companies by rejecting claims, nothing more, is “insufficient to reach the level of a legally identifiable conflict of interest”.  Id. (citing Pitman v. Blue Cross & Blue Shield of Okla., 217 F.3d 1291, 1296 (10th Cir.2000)).   We therefore examine the denial of benefits by Horizon under a “purely” arbitrary and capricious standard. TRENTON – The New Jersey Department of Banking and Insurance announced today that it has determined that Horizon Blue Cross Blue Shield of New Jersey`s application to revamp its corporate structure as a nonprofit holding company has been completed. The application is available at nj.gov/hschearings/ and information on how to register to attend future public hearings.

The Department will hold three public hearings on the proposed establishment of a mutual holding company, as required by legislation (P.S. 2020, c. 145). “As part of the public consultation, Horizon Blue Cross Blue Shield of New Jersey will outline its reorganization plan as a mutual holding company,” said Commissioner Marlene Caride. “The public will have several opportunities to exchange feedback on the application and planning through an in-person hearing, two virtual meetings and written submissions.” Information on the public hearing is available below: Our review of summary judgment orders is de novo and applies the same standard as the district court.  LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789, 795 (10th Cir.2010).   In this case, the parties have raised this issue in response to summary judgment counterclaims, and we must determine the standard of review, regardless of the district court.  Id., p. 796.

Mr S. and Horizon filed interlocutory motions on 6 July 2010.   Aplt.App. 12-13, 56-58.   On the same day, Horizon also filed a statement, including the terms of transferring authority from Horizon to Magellan to manage mental health claims in a Provider Services Agreement (“VSA”).   Aplt.App. 95a-134a.   Mr. S. requested that this declaration be deleted because it is time-barred and obsolete.   Aplt.App.

238-244a.   The District Court Aplt.App rejected the strike request. 337–43 and granted Horizon summary judgment Aplt.App. 323–36.   The district court ruled that an “arbitrary and capricious” standard of review applied and that neither Horizon nor Magellan acted arbitrarily or capricious in challenging the impugned claim.   Aplt.App. 327-36.  Mr S. submits that the Bezirksgericht erred in refusing to cancel the VSA and in concluding that its registration was harmless.   Aplt.

Br. 28.   Mr. S. did not and never questioned Magellan`s authority to act as an external plan administrator on behalf of Horizon.   Our jurisprudence recognizes that such delegations occur without changing the applicable standard of review.  Geddes v. United Staffing Alliance Emp. Med.

Plan, 469 F.3d 919, 926 (10th Cir.2006);  Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 801 (10th Cir.2004). Without first establishing that the SPD was part of the plan, the District Court wrongly relied on the SPD`s wording. We forget this mistake because the SPD says unequivocally that it is part of the plan, but the best practice is to proceed in the right order of determination. How would you rate your overall experience with this company? EUGENE S., Plaintiff-Appellant, v. HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, Appellant Respondent. B. If Horizon suffers from a conflict of interest Learn more about FindLaw`s newsletters, including our Terms of Use and Privacy Policy.  Our colleagues from other quarters have repeatedly said that an SPD can be part of the plan. See, for example, Pettaway v. Teachers Ins. & Annuity Ass`n of Am., 644 F.3d 427, 434 (D.C.Cir.2011);  Heffner v.

Blue Cross & Blue Shield of Ala., Inc., 443 F.3d 1330, 1342–43 (11th Cir.2006);  Bergt v. Rotten. Plan for pilots employed by MarkAir, Inc., 293 F.3d 1139, 1143 (9th Cir.2002).   However, an insurer is not entitled to a deferential examination simply because it claims that the SPD is integrated into the plan. Instead, the insurer must prove that the SPD is part of the plan, for example by clearly indicating on the front that it is part of the plan. A contrary decision would harm Amara. If you have any other questions about your benefits, please call the number on your ID card during regular business hours or sign up to send a secure email 24/7. Eugene S. applied for reimbursement of the costs of her son A.S.`s hospital treatment from his employer`s ERISA insurance.

  Aplt.App. 1 to 6.   Magellan Behavioral Health of New Jersey, LLC (“Magellan”), initially denied the application, stating that Mr. S.`s son was qualified for intensive outpatient treatment, but not for inpatient treatment.   Magellan confirmed his initial refusal to provide hospital treatment services in several appeals filed by Mr. S. and the hospital treatment centre.   On Mr S.`s last appeal, Magellan authorised and granted benefits for inpatient treatment between 10 August and 2 August. In November 2006, however, he reiterated that Mr. S.

was entitled to intensive non-hospital treatment only between 3 November 2006 and 12 June 2007 and refused hospital treatment during that period.  After exhausting his administrative claim, Mr. S. filed this action on July 24, 2009, against Horizon`s refusal to provide benefits under ERISA (29 U.S.C. § 1132(a)(1)(B)).  The parties consider whether Magellan erred in denying benefits under its “continuous residence” criteria.   They focus most of their discussion on the first of the five criteria for an additional covered stay, just like us. 2.

Counsel assured the court that the only unsubstantiated document of the plan – the “group policy” or the “group certificate” – relates solely to the relationship between Horizon as plan administrator and Mr. S.`s employer. as the plan sponsor and has no effect on Horizon`s discretion in reviewing claims.  (Oral arg. 15:00 to 16:52). The District Court legitimately exercised its discretion.   The VSA became relevant because Mr. S. alleged a dual conflict of roles.

  Before that, there was no reason for Horizon or Magellan to include the VSA in the administrative file.   The district court could not hope to assess this alleged conflict without the United States. Given that our jurisprudence permits the introduction of additional evidence relating to a dual-role conflict and that Horizon`s failure to disclose the VSA under Rule 26 is unfortunate to Mr. S. was harmless, justified by Mr. S.`s assertion or both, we will not set aside the District Court`s judgment. In the Amara case, the Supreme Court examined, in particular, whether a district court may enforce conditions in a SPD if those conditions conflict with the conditions set out in the planning documents.  Amara, 131 S.Ct. at 1876-78 (verify whether plan members could “recover benefits due to improper disclosures”).