Take a look at Krodel v. Bayer Corp., 2005 U.S. Dist. LEXIS 26833 (D. Mass. 2005). It involved a claim by a physician for payment of a replacement of his prosthetic leg. Boiled down to its essence, the doctor wanted a technologically advanced, relatively expensive prosthesis that provided him the maximum utility. Bayer, the sponsor of the ERISA plan, wanted to provide him with a more basic, less functional and relatively inexpensive replacement prosthetic leg.
The court ruled in favor of the doctor. The crux of the opinion is on pp. 12-17. Bayer’s plan document stated that a medical supply was covered if it is "of proven value and not redundant with other procedures." However, Bayer interpreted this language to also require that the doctor prove "there are no other reasonable alternatives which would achieve a comparable therapeutic benefit for the patient, in terms of enabling the patient to perform activities of daily living." The court rejected Bayer’s attempt to impose what the court felt was an added restriction to the coverage language of the plan document.
Bayer complained that the court’s ruling would require it to supply Cadillacs rather than Fords to plan beneficiaries. The court responded by saying that, in this situation, the plan document language required Bayer to provide a Cadillac. If Bayer wanted, it could change the language of the plan document. But until then, the plan beneficiaries were entitled to the benefits promised to them.
Krodel illustrates that quite often a person’s entitlement to benefits turns on a very small pivot. Specific plan language, specific facts; these make the difference between winning and losing in many ERISA cases.