Opinion ID: 157649
Heading Depth: 2
Heading Rank: 2

Heading: Reviewability of APM Criteria

Text: 14 In granting KMED's second motion for summary judgment, the district court found that the unpublished APM criteria were part of the Plan's terms and, hence, that it could not review them. We agree. 15 A plan participant has a right to know where she stands with respect to her benefits. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 118, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Blair v. Metropolitan Life Ins. Co., 974 F.2d 1219, 1221 (10th Cir.1992). However, ERISA's disclosure provisions do not require that the plan summary contain particularized criteria for determining the medical necessity of treatment for individual illnesses. See Stahl v. Tony's Bldg. Materials, Inc., 875 F.2d 1404, 1407 (9th Cir.1989); Pompano v. Michael Schiavone & Sons, Inc., 680 F.2d 911, 914 (2nd Cir.1982). Indeed, such a requirement would frustrate the purpose of a summary--to offer a layperson concise information that she can read and digest. See Stahl, 875 F.2d at 1409. In the instant case, the Plan Summary expressly authorized APM to determine eligibility for substance abuse treatment according to its own criteria. The APM criteria did not need to be listed in Plan documents to constitute part of the Plan. 16 Because we consider the APM criteria a matter of Plan design and structure, rather than implementation, we agree that a court cannot review them. See Averhart v. U.S. WEST Management Pension Plan, 46 F.3d 1480, 1488 (10th Cir.1994); see also Hein v. Federal Deposit Ins. Corp., 88 F.3d 210, 215 (3d Cir.1996) (court must enforce plan as written unless it violates a specific ERISA provision). ERISA does not mandate that employers provide any particular benefits. Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 91, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983). Indeed, an employer may draft a benefits plan any way it wishes; it does not act as a fiduciary when it sets the terms of the plan. See Averhart, 46 F.3d at 1488. We hold that the district court properly granted summary judgment for KMED on the issue of whether the APM criteria were arbitrary and capricious.