Full opinion text
OPINION AND ORDER ON MOTION FOR SUMMARY ADJUDICATION BRAZIL, United States Magistrate Judge. I. INTRODUCTION Donald Lancaster (“Lancaster”) suffered serious head injuries after being hit by a car. He is now confined in a nursing home, where he needs total assistance for virtually all his daily living activities. Lancaster’s conservator enrolled him in United States Shoe (“U.S. Shoe”) Corporation’s health care plan for retirees. U.S. Shoe has declined to pay benefits for Lancaster’s confinement, relying primarily on two grounds: (1) Lancaster exhausted a 365-day limit in the benefits plan on convalescent care benefits; and (2) the care Lancaster received was “custodial” and, hence, not “medically necessary.” Lancaster’s conservator has filed an ERISA action against U.S. Shoe and has moved for summary adjudication. We conclude that U.S. Shoe’s denial of benefits was based on a legally impermissible interpretation of the benefits plan. We hold that, with one undisputed exception, the 365-day limit on convalescent care benefits is unenforceable. While the 365-day limit that U.S. Shoe attempts to enforce was in the benefits plan itself, it was not in the summary plan description. Where the summary plan description conflicts with the terms of the plan, the summary plan description controls. We further hold, applying the doctrine of reasonable expectations, that it was improper for U.S. Shoe to deny benefits on the grounds that the care Lancaster received was “custodial.” We find that, based on the summary plan description, an insured would have reasonable expectations of coverage for nursing home care in circumstances similar to those in which Lancaster finds himself. The summary plan description does not state that coverage for nursing home care is not provided if the care is “custodial” and does not state that care is not “necessary” if it is “custodial.” As we explain in detail below, denying coverage on the basis that care is “custodial” conflicts with the reasonable expectations of the insured. We grant Lancaster’s motion for summary adjudication. We remand this case to the administrator of the benefits plan for further proceedings in accordance with this opinion. We retain jurisdiction. II. FACTS A. Lancaster’s Accident 1. On December 15, 1988, Lancaster was struck by a car. Lancaster Deck (LD) at 2. At the time, he was an employee of U.S. Shoe. LD 2. As a result of the accident, Lancaster sustained major injuries, including head injuries. LD 2-3. He was taken to Santa Monica Hospital.. AR- 106. For a while, Lancaster was in a coma. LD 3. 2. Lancaster eventually emerged from the coma. LD 3. He was released from Santa Monica Hospital into a skilled nursing facility, Synergos Neurological Center, on May 5, 1989. LD 3; AR 106. In June 1990, Lancaster was transferred from Synergos into Greenridge Convalescent Hospital (“Greenridge”), another skilled nursing facility. LD 3; see also infra ¶ 19. Lancaster has remained at Greenridge since June 1990. LD 3. Lancaster requires total assistance for virtually all of his daily living activities. LD 3. 3. Donald Lancaster’s injuries left him unable to handle his affairs. LD 3. A court appointed John Lancaster, Donald’s brother, to serve as Donald’s conservator. LD 3. B. The Benefits Plan 4. U.S. Shoe provides its employees with a health benefits plan — the United States Shoe Corporation Health Care Protection Plan (“the Plan”). Muntel Deck (MD) at 2. The Plan is self-funded. MD 2. The head administrator of the Plan is the U.S. Shoe Benefit Committee (“the Benefit Committee”). MD 2. The Benefit Committee delegates most of its authority to administer the Plan, including the authority to process claims and to pay or deny claims, to Pruden- ■ tial Insurance Company of America (“Prudential”). MD 2. The Benefit Committee reviews appeals of claims determinations by Prudential. 5. U.S. Shoe summarized the contents of the Plan for its employees by preparing and distributing a summary plan description (SPD). U.S. Shoe has provided the court with three different SPDs, each bearing different dates. The earliest SPD is dated “1/84” (henceforth, “the 1984 SPD”). Hakes Deck (HD), Ex. A. The second SPD is dated “4/1/89-3/31/90” (henceforth, “the 1990 SPD,” or simply “the SPD”). HD, Ex. B. The third SPD is dated “Sept. 1991” (henceforth, “the 1991 SPD”). HD, Ex. C. As we will explain below, the SPD that is controlling for purposes of our decision is the 1990 SPD. See infra § 111(E)(4). 6. At some time prior , to July 20, 1990, the. conservator’s attorney reviewed the 1990 SPD. See AR 23. The 1990 SPD has the following important provisions. In an introductory section, the SPD states: The Health Care plan provides protection against expenses you and your dependents may incur due to illness or injury. The choices which are available vary in the portion of the expenses you are required to pay. All the choices, however, protect you from the [sic] financial' ruin due to a catastrophic condition. HD, Ex. B at 9 (emphasis added). The SPD also states that “[a] one million dollar lifetime cap has been placed on health care benefits for each person covered.” HD, Ex. B, second (not numbered) page. 7. The SPD has a section entitled “Extended Convalescent Care Benefits.” In its entirety, that section states: In order for any expenses to be covered, confinement in the Facility must start within 14 days following discharge from a hospital confinement of a minimum of three consecutive days. If necessary and reasonable, the following expenses are covered: 1. Room and board provided by the Facility except any charge that exceeds the Daily Room and Board Benefit of $18 to a maximum of $6,570 per disability. 2. Routine nursing care provided by the Facility, but not including a private duty nurse or other private-duty attendant. 3. Physical or speech therapy provided by the Facility or by others under arrangements with the Facility. 4. Medical social services provided by the Facility. 5. Such drugs, biologicals, supplies, appliances and equipment as are ordinarily provided by the Facility. 6. Medical services provided by an intern or residént-in-training of a hospital with which the Facility has a transfer agreement under a teaching program of the hospital but not including any other medical care or treatment by a doctor, including a resident doctor or intern, and other diagnostic and therapeutic services furnished to in-patients of the Facility by a hospital, and 7. Such other services necessary to .the health of the patients as generally provided by the Facility. Successive periods of confinement will be treated as one confinement unless: a. The subsequent confinement is due to a completely unrelated cause or commences after complete recovery, or b. In the case of your personal coverage, you have returned to active full-time work between confínéments, or c. In the case of your dependent at least 90 days have elapsed between confinements. HD, Ex. B at 18. 8. In its “Definitions” section, the SPD defines “Extended Care Facility” as “an institution, or a distinct part of an institution, which has qualified as an Extended Care Facility for Medicare.” HD, Ex. B at 9. The SPD defines “Home Health Care Agency” as an organization, or its distinct part which, a. Is primarily engaged in providing skilled nursing care and other therapeutic services for, and in the private residences of, persons recovering from an injury or disease, and d. Is not, other than incidentally, engaged in providing care or treatment of mentally ill, or in providing custodial-type care. HD, Ex. B at 9 (emphasis added). Part of the SPD’s definition of “Hospital” is “[a]n institution which ... [i]s not primarily a place for rest or the aged ... or a nursing or convalescent home.” HD, Ex. B at 10. The SPD defines “Illness” as a “[bjodily disorder or accidental injury or mental infirmity,” adding that “[sjuceessive bodily disorders and mental infirmities due to the same cause or related cause [sic] will be considered as one illness.” HD, Ex. B at 10. 9. The SPD has a section called “Excluded Expenses.” Within that section, the SPD states that coverage is not-provided for [s]ervices and supplies not reasonably necessary. To be “reasonably necessary”, a service or supply must be ordered by a doctor and be commonly and .customarily recognized throughout the doctor’s profession as appropriate in the treatment of the diagnosed sickness or injury. It must neither be educational or experimental in nature, nor provided primarily for research. Also, the length of a hospital confinement and the hospital’s services and supplies will be “reasonably necessary” only to the extent they are, as determined by Prudential* reasonably related to the treatment of the condition involved and not allocable to the patient’s scholastic education or vocational training. HD, Ex. B at 22. 10. The SPD has a section entitled “Home Health Care Benefits.” In that section, the SPD states, “Expenses due to the following are not covered Home Health Care Expenses: ... Care comprised of services and supplies which are provided to a Covered Individual primarily as custodial care assisting him in the activities of daily living.” HD, Ex. B at 17. 11. A section entitled “General Expenses” provides coverage “for payment up to 80% of the reasonable and customary amount” for “[n]ursing, speech therapy, physiotherapy or occupational therapy not rendered by yourself, spouse, or a child, brother, sister, or parent of yourself or spouse.” HD, Ex. B at 21. 12. The SPD states, “In general, your participation in the Flexible Benefit Program ends on the date you stop working ... However, you may be able to continue participation in the Program by taking the proper actions.” HD, Ex. B at 3. The SPD adds, “Employees eligible for an immediate payout of retirement benefits may be offered the option to continue their own and their dependents’ participation in the Health Care plan.” HD, Ex. B at 4. 13. The 1984 SPD is significantly different from the 1990 SPD. The most important difference, for our purposes, is that the 1984 SPD does not have a section addressing “Extended Convalescent Care Benefits.” See HD, Ex. A. The 1984 SPD does have a section which states that coverage is given for “Nursing Care — Private duty nursing by a registered graduate nurse,” “In or Out of the Hospital.” HD, Ex. A at 41. 14. The 1991 SPD, on the other hand, is very similar to the 1990 SPD. There are only two differences of potential significance. The first is that the language “[i]f necessary and reasonable, the following expenses are covered,” in the “Extended Convalescent Care Benefits” section of the 1990 SPD, is replaced in the 1991 SPD by the language “[i]f the charges are usual and prevailing, the following expenses are covered.” HD, Ex. C at 17. The second difference is that the exclusion for “[services and supplies not reasonably necessary” is replaced in the 1991 SPD by an exclusion for “[s]ervices and supplies not medically necessary.” HD, Ex. C at 20 (emphasis added). The exclusion in the 1991 SPD states: ' To be ‘medically necessary,’ a service or supply must be ordered by a physician, must be commonly and customarily recognized throughout the physician’s profession as appropriate in the treatment of the diagnosed sickness or injury and must be generally accepted by United States medical standards. It cannot be educational not [sic] experimental or investigational in nature. ‘Educational’ means that the primary purpose of the service or supply is to provide a patient with any of the following: training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities. “Experimental or investigational” means that the medical use of a service or supply is still under study and the service or supply is not yet recognized throughout the physician’s profession in the United States as safe and effective for diagnosis or treatment. Services or supplies which are provided only because an unnecessary service or supply is being provided will also be considered not needed. The length of a hospital confinement and the hospital’s services and supplies will be “medically necessary” only to the extent that they are, as determined by the Claim Administrator, reasonably related to the treatment of the condition involved and not allocable to the patient’s scholastic education or vocational training. HD, Ex. C at 20. 15. The Plan itself is a document separate from the SPD. The Plan has the following important provisions. The Plan states: The Benefit Committee shall have the power to administer this Plan and also such additional powers as may be conferred upon it by the Trust, including without limitation, the following powers ...: (b) to interpret and construe this Plan in a nondiscriminatory manner consistent with its terms and provisions and with Section 501(c)(9) of the Internal Revenue Code of 1954, as amended; to determine all questions of eligibility and the status and rights of Employees, Qualified Dependents and others; to determine the benefits payable under this Plan and, where applicable, the method of distribution thereof; to make and enforce rules and regulations relating to such determination; and to decide such questions as may arise in connection with the operation of this Plan, whether or not specifically covered by any provision of the Plan; ... PD, Ex. C. 16. The Plan has a provision entitled “Convalescent Nursing Home Care Provisions Under Major Medical Expense Benefits.” This provision states: The term “Convalescent Nursing Home” means only an institution meeting the following requirements: (1) It is operated pursuant to law and is primarily engaged in providing, for compensation from its patients, the following services for persons convalescing from sickness or injury — room, board and twenty-four hour a day nursing service by one or more professional nurses and such other nursing personnel as are needed to provide adequate medical care. (2) It provides such services under the full-time supervision of a proprietor or employee who is a Physician or a registered graduate nurse (R.N.). (3) It maintains adequate medical records, and has available the services of a Physician under an established agreement if not supervised by a Physician. (4) It has established methods and procedures for the dispensing and administering of drugs and biologicals. (5) It has a written transfer agreement in effect with one or more hospitals. The term “Convalescent Nursing Home” shall not include any institution or part thereof which is used principally as a rest facility for the aged, for drug addicts, for alcoholics or for the mentally ill. For the purpose of the Major Medical Expense Coverage, when charges are made by a Convalescent Nursing Home for the additional services and supplies described below which are furnished during a person’s confinement therein and while the conditions set forth below are satisfied, those charges shall be considered charges made by a Hospital and that confinement shall be considered a Hospital confinement. Additional Services and Supplies: Subsection (1) and (2) of the [Major Medical Expense] Coverage are enlarged to include the following additional services and supplies— (a) Convalescent Nursing Home room and board (including regular daily services and supplies furnished by the Convalescent Nursing Home); (b) Routine nursing care provided by the Convalescent Nursing Home but not including the services of a private-duty nurse or other private-duty attendant; (c) Physical or speech therapy provided by the Convalescent Nursing Home or by others under arrangements with the Convalescent Nursing Home; (d) Medical social services provided by the Convalescent Nursing Home; (e) Drugs, biologicals, supplies, appliances and equipment as are ordinarily provided by the Convalescent Nursing Home for the care and treatment of its inpatients; (f) Medical services provided by an intern or resident-in-training of a hospital with which the Convalescent Nursing Home has in effect a transfer agreement under a teaching program of such hospital; and (g) Other services and supplies, exclusive of professional services, furnished by the Convalescent Nursing Home for medical care therein. Limitations — The additional services and supplies shall be included only: (1) If furnished during no more than three hundred sixty-five days of the person’s Convalescent Nursing Home confinement due to the same or related causes, and (2) To the extent that the room and board charges therefor do not exceed a daily limit of $18.00. Conditions: All of the following— (1) The person was confined in a Hospital for a least three consecutive days. (2) The Convalescent Nursing Home confinement is recommended by his Physician for convalescence from a condition which caused such Hospital confinement, or from a related condition, and commences (a) within fourteen days after discharge from such Hospital confinement or (b) within fourteen days after a related Convalescent Nursing Home confinement. (3) He is under the continuous care of his Physician. (4) Twenty-four hours a day nursing care of the person is essential, as certified by his Physician. Related Convalescent Nursing Home Confinements: Separate Convalescent Nursing Home confinements of a person will be considered related unless— (1) the later confinement commences after complete recovery from the illness causing an earlier confinement, or (2) the later confinement results from causes entirely unrelated to the causes of an earlier confinement, or (3) in the case of an Employee, the confinements are separated by his compliance with the active work requirement of the General Definitions, or (4) in the ease of a dependent of the Employee, the confinements are separated by at least ninety days. PD, Ex. E (bold emphasis added). 17. The Plan also has a section entitled “Convalescent Nursing Home Expense Benefit Provisions Under Hospital Expense Benefits.” MD, Ex. A at CNH-2A. There are no material differences, for purposes of this case, between this section and the section entitled “Convalescent Nursing Home Care Provisions Under Major Medical Expense Benefits.” See MD, Ex. A at CNH-2A. 18. The Plan excludes payment for “Charges for Unnecessary Services and Supplies,” defined as “charges for any service or supply not reasonable necessary for the medical care of the patient’s sickness or injury; charges made by a Hospital to the extent that they are allocable to scholastic education or vocational training of the patient, as determined by the Employer.” PD, Ex. D. 18b. Part of the Plan’s definition of “Hospital” states: In no event-shall the term “Hospital” include a convalescent nursing home or in-elude an institution or part thereof which (i) is used primarily as a convalescent facility, rest facility, nursing facility or facility for the aged, or (ii) furnishes primarily domiciliary or custodial care, including training in the routines of daily living, or (iii) is operated primarily as a school. PD, Ex. D. 19. Both parties agree that Greenridge is a “convalescent nursing home” as defined by the Plan. See The United States Shoe Corporation’s Separate Statement of Undisputed Facts at 3; Astabie Decl., Ex. A, Ex. B. C. Lancaster’s Enrollment in the Retiree Benefits Plan 20. The conservator learned that U.S. Shoe had given Lancaster the status of a retired employee because Lancaster was totally disabled. LD 3. Responding to inquiries, Prudential wrote a letter on March 27, 1990, to the conservator’s attorney, which stated: This letter is to provide clarification on the Extended Convalescent Care Benefits as provided by the U.S. Shoe Plan. The Plan allows $18.00 for Room and Board at 100% for 365 days for a maximum of $6,570.00 per disability. Once this $18.00 daily Room and Board benefit is exhausted, the balance of the Room and Board is not eligible. The other ancillary charges provided by the facility such as physical or speech therapy, drugs, etc. would be payable at 80% for an unlimited number of days as long as services are medically necessary and Mr. Lancaster remains covered under the Plan. Administrative Record (AR) 13 (emphasis added). 21. On May 17,1990, U.S. Shoe wrote the conservator a letter, stating that Lancaster was eligible to be enrolled in U.S. Shoe’s retiree medical plan for a $34.49 monthly premium. AR 15. In a letter directed to Lancaster, addressed to the care of the conservator and dated July 16, 1990, Ü.S. Shoe stated, “To continue the medical insurance you currently have w-ould cost $34.49 per month.” AR 21. The conservator enrolled Lancaster in U.S. Shoe’s retirees’ health benefits plan on July 20, 1990. LD 3; LD, Ex. A. 22. In a letter dated July 19, 1990, the conservator’s attorney asked U.S. Shoe to confirm the following: As a member of the Retiree’s Health Plan, [Lancaster] is entitled to all benefits that he was entitled to and receiving as an active employee as set forth in U.S. Shoe’s Flexible Benefits Policy dated 4/1/89 to 3/31/90, including but not limited to page 18 Extended Convalescent Care Benefits. The only difference between the active employee’s health care benefits and the retiree’s health care benefits is that payments made by Prudential under the Retiree’s Health Plan are reduced by whatever payment is made by Medicare. AR 23 (emphasis in original). In a letter dated August 20,1990, Prudential stated that it was “able to concur” with those two statements, except that “[i]n addition to this [‘only’] difference, a retiree does not have to comply with two of U.S. Shoe’s cost-containment features, the Pre-Certification requirement for inpatient hospital stays (PACRS) and the Second Opinion Program for inpatient surgery (SSOP).” AR 27. D. Prudential’s Cessation of Benefits 23. Prudential paid benefits for charges incurred for Lancaster’s confinement at Greenridge through June 1993. LD 3. Prudential stopped paying for the Greenridge charges in July 1993, and has not paid for any Greenridge charges since. LD 3. 24. Between July 1993 and July 1994, theré were oral and written communications between the conservator’s attorney and Prudential regarding the status of payment for the Greenridge charges. See AR 41-52. According to Prudential claim file notes dated December 16, 1993, a Prudential claims representative told the conservator’s attorney in a phone conversation that “[t]he U.S. Shoe Plan is set up to only cover expenses medically necessary to the treatment] of ah illness or injury, not to maintaining a condition” .and that “CONVALESCENT means ‘getting well, one who is recovering from a disease or operation, the period of recovery after the termination of a disease or an operation’ as defined by [a] Medical Dictionary.” AR 265. 25. In a letter to Prudential dated July 26, 1994, the conservator’s attorney described a telephone conversation that purportedly took place between him and a Prudential representative on July 20, 1994. According to the attorney, the Prudential representative advised him in that phone conversation that Lancaster was not entitled to benefits because “the word ‘convalescent,’ which appears in the U.S. ■ Shoe policy, is defined in some medical dictionary as progressing toward health, or getting better, and since Mr. Lancaster seems to have stabilized, he therefore has no coverage.” AR 56. In the same letter, the attorney asked Prudential to clarify its position. AR 58. 26. In a letter to the conservator’s attorney dated July 25, 1994, Prudential stated: We contend that the services rendered to Mr. Lancaster at Greenridge Heights Convalescent Hospital are custodial in nature____ Prudential defines custodial care as “Care that provides a level of routine maintenance for the purpose of meeting personal needs. This is care that can be provided by a lay person who does not have professional qualifications, skills or training. Custodial Care includes, but is not limited to: help in walking and getting into or out of bed; help in bathing, dressing, and eating; help in other functions of daily living or similar nature; administration of. or help in using or applying medications, creams and ointments; routine administration of medical gasses after a regimen of therapy has been set up; routine care of a patient, including functions such as changes of dressings, diapers and protective sheets and periodic turning and positioning in bed; routine care and maintenance in connection with casts, braces and other similar devices, or other equipment and supplies used in treatment of a patient, such as colostomy and ileostomy bags and indwelling catheters; routine tracheostomy care; general supervision of exercise programs including carrying out of maintenance programs of repetitive exercises that do not need the skills of a therapist and are not skilled rehabilitation services.” AR. 53-54 (emphasis added). E. Lancaster’s Medical Condition 27. A document entitled “Medical Referral” and date-stamped August 5,1994, apparently from Prudential’s claims department, addressed to Prudential’s “Medical Department,” asks the medical department to resolve only one issue in order to enable Prudential to determine whether benefits to Lancaster should be paid — “Áre the services medically necessary in diagnosing/treating the patient’s illness? Or is care custodial?” AR 291. In a document dated August 8, 1994, Dr. Earnest Austin of Prudential’s medical department gave a three-word response — “Care is custodial.” AR 292. 28. In a deposition taken for purposes of this litigation, Austin stated that Lancaster’s medical records indicate that he is unable to ambulate, needs assistance in daily living, and is almost a total care resident. PD, Ex. H at 35. Austin stated that the records indicate that Lancaster needs assistance in all his daily living activities, except that he is able to feed himself when food is presented to him. PD, Ex. H at 36. 29. Austin stated that the medical records indicate that Lancaster was not receiving any skilled care at Greenridge — “care that required specialized skills [and] can only be rendered by a nurse ...” PD, Ex. H at 35-36. Austin stated that it was his opinion that it would be appropriate for Lancaster to be in a facility where he ordinarily receives care from nurses’ aides or other caretakers who are not nurses but where a nurse is available if necessary. PD, Ex. H at 53. 30. The medical records in Prudential’s claim file indicate that Lancaster needs to be fed a “mechanical soft diet” and “thickened liquids” and needs to be supervised when feeding, in order to avoid a danger of choking that is related to difficulty in chewing and swallowing. See AR 528, 552, 606, 607, 680, 755, 1150, 1156. One notation in the medical records states that, due to Lancaster’s head injuries, there is “potential for shortness of breath,” and that, in order to deal with this problem, Lancaster’s attendants are required to “observe closely for shortness of breath,” “notify MD as needed,” and “educate and encourage resident to use call light when having difficulty.” AR 1165. 31. The records also show that Lancaster must wear a seatbelt when in his wheelchair, must have two side rails up while in bed, and “requires proper body alignment at all times,” for safety, to prevent him from sliding and pitching forward and falling out of his wheelchair or bed. See AR 742, 755, 1149, 1153. Furthermore, the records show that Lancaster’s body needs to be periodically repositioned and that his extremities need to be periodically taken through their full range of motion, in order to reduce the risk of an ulcer related to immobility and to treat “contractures of upper and lower extremities.” See AR 1148, AR 1154. In addition, the records show that Lancaster is incontinent. AR 1147. 32. Lancaster’s medical records indicate that he received physical and speech therapy early in the course of his confinement at Greenridge, at least in his first two months there. This therapy apparently did not continue past Lancaster’s first few months at Greenridge. See AR 590, 601, 682, 1377. 33. According to a declaration by Lancaster’s physician, Lancaster needs to be in a skilled nursing facility because of his medical condition, especially because of the danger of choking created by his swallowing difficulties. De los Reyes Decl. at 3-4. According to the physician, no residential care facility would accept a patient in Lancaster’s condition. De los Reyes Decl. at 3. F. Prudential’s Denial ofBenefíts 34. On August 10, 1994, Prudential wrote a letter to the conservator’s attorney, stating that it was denying payment for the Green-ridge charges. Pritikin Decl. (PD) at 3. In the letter, Prudential stated that its “Medical Department” had reviewed Lancaster’s claim. PD, Ex. B. Prudential stated that the “Medical Director” had determined that “the services rendered are custodial in nature.” PD, Ex. B. Prudential added, “Care that is not medically necessary is not eligible for reimbursement under the U.S. Shoe Group Plan and custodial care does not meet the U.S. Shoe definition of ‘medically necessary services/supplies.’” PD, Ex. B. Prudential also stated that it had improperly paid charges for confinement at Greenridge prior to July 1993, and requested a refund from the conservator in the amount of $59,-114.42. PD, Ex.B. 35. On September 23,1994, the conservator’s attorney sent a letter to Prudential, appealing Prudential’s denial of Lancaster’s claim. PD 3; AR 75-77. On October 20, 1994, Prudential wrote the conservator’s attorney a letter, denying the appeal, and advising that any further appeal would have to be directed to U.S. Shoe. PD 3. The letter stated: It is our position that not only has Mr. Lancaster’s confinements [sic] in the extended care facilities exceeded the policy limitations, it has been determined that the services being rendered are primarily custodial care for aid to daily living functions. Our Medical Department has reviewed the information submitted by the providers of these services and has concluded that this care could have been provided by a lay person who does not have professional qualifications, skills or training. AR 101. G. U.S. Shoe’s Denial of Lancaster’s Appeal 36. On November 9, 1994, the conservator’s attorney sent a letter to U.S. Shoe, appealing Prudential’s denial of Lancaster’s claim. PD 3. A cover letter from an unidentified U.S. Shoe employee to U.S. Shoe’s Benefit Committee states the following: Attached for your review is a claim appeal regarding payment of convalescent care benefits. The associate was seriously injured when he was struck by an automobile in December 1988. He was hospitalized in Santa Monica Hospital from December 1988 until May 1989. On May 5, 1989 he was transferred to Synergos Neurological Center for extended convalescent care and in June 1990 transferred to Greenridge Heights Convalescent Hospital. Greenridge Hospital was billing room & board, charges as $18.00/day at the associate’s family’s request since this is the amount covered by Prudential for room & board. The actual room & board, charge was $105.00/day. The additional $87.00/day was being billed as professional fees (including room & board, nursing care, food, maintenance, and dietary professional fees). The extended convalescent care benefits available to this associate were exhausted when he met the maximum benefit allowed for this disability — $6,570 (see attached copy of extended convalescent care benefits per SPD). However, all charges at Greenridge Hospital have been determined by both Prudential and Medicare to be ineligible since they are custodial in nature. Prudential has overpaid the benefits by $59,114.42. Due to a dispute in the billing practices, Prudential stopped paying charges at Greenridge Hospital in September 1993. There is a dispute between Prudential and the associate as to whether or not the care given is “medically necessary” ____ AR 118 (emphasis added). 37. A notation by a Prudential claims representative in Prudential’s claim file states that an official at Greenridge had told her that the total cost of Lancaster’s residency was $105 per day and that the $105 included room and board, “nursing care, food, maintenance, dietary prof, fees.” The notation also states that Greenridge “accommodated their fees for the patient’s family” by billing only $18 per day for room and board in order to match the $18 per day room and board limit in the SPD. AR 262. 38. All the members of the Benefit Committee voted to deny Lancaster’s appeal. The notes of the members of the Benefit Committee indicate that the major reasons for the denial were that the care given was custodial, that the care had been determined by Prudential not to be medically necessary, and that the Plan limits convalescent care benefits to one year. See AR 154-161. 39. On February 21, 1995, the chair of U.S. Shoe’s Benefit Committee wrote to the conservator’s attorney, stating that Lancaster’s appeal had been denied. PD, Ex. B. The letter stated: The grounds for denial is [sic] based upon the fact that the benefit plan limits the payment of extended convalescent care benefits to a maximum of $6,570 per disability. Additionally, the group plan does not cover and will not pay for charges incurred for unnecessary services, that means services or supplies “not reasonably necessary for the medical care of the patient’s sickness or injury.” This includes custodial services. PD, Ex. B. H. Legal Proceedings 40. The conservator filed an ERISA action. The conservator requests payment of benefits for confinement at Greenridge after July 1993. The conservator also requests a declaration of the parties’ rights and duties with respect to payment of benefits for continued confinement at Greenridge. The conservator further asks for prejudgment interest, attorney’s fees, and costs. First Amended Complaint at 4-5. U.S. Shoe has filed a counter-claim, requesting repayment of the alleged overpayment of benefits. Answer and Counter-Claim at 4. 41. Plaintiff has moved for summary adjudication of issues. Plaintiff requests that this court either reverse U.S. Shoe’s denial of coverage or remand the case for further administrative proceedings. III. ANALYSIS A. Reasons for the Denial of Lancaster’s Claim In their correspondence with the conservator’s attorney, U.S. Shoe and Prudential explicitly gave two reasons for denying benefits to Lancaster. The first was that the care given to Lancaster was not “reasonably necessary” or “medically necessary” but, instead, was merely custodial. See supra ¶¶ 34, 35, 39. In its correspondence, Prudential distinguished “custodial” care from “necessary” care mainly on the basis that “custodial” care is “care that can be provided by a lay person who does not have professional qualification, skills, or training.” See supra ¶¶ 26, 35. The second reason given was that Lancaster had exceeded a 365-day limit on “Extended Convalescent Care Benefits.” See supra ¶¶ 35, 39. A careful examination of the record reveals that two other considerations may have played some role in the denial of benefits by Prudential and/or by U.S. Shoe. The first of these two considerations was that U.S. Shoe and/or Prudential may have believed that all the charges made by Greenridge were for “room and board.” See supra ¶¶ 36, 37. The second consideration that may have played some role in the denial of benefits, at least in the lower levels of Prudential’s review of Lancaster’s claim, was an apparent belief, based on the definition of the word “convalescent,” that “Extended Convalescent Care Benefits” could only be awarded for care that helped a patient progress toward recovery from an illness or injury, not care that only maintained a patient’s condition. See supra ¶¶ 24r-26. In addition to surfacing in telephone conversations between a Prudential claims representative and the conservator’s attorney, see supra ¶¶ 24r-25, this consideration appears to be present in part of Prudential’s definition of “custodial care”— “[c]are that provides a level of routine maintenance for the purpose of meeting personal needs.” See supra ¶26 (emphasis added). In order to be thorough, we will rule on the validity of all four considerations that may have played a role in the decisions of Prudential and/or U.S. Shoe — both the two reasons that were given explicitly and the two reasons that may have played a role internally. We must now determine what standard to use to review the validity of the four considerations. B. Doctrinal Overview I Abuse of Discretion Standard U.S. Shoe wishes the court to review the denial of benefits under only one standard— the “abuse of discretion” standard, also called the “arbitrary and capricious” standard. “A determination that denies benefits under an ERISA plan is reviewed de novo ‘unless the benefit plan gives the administrator or fiduciary discretionary authority to construe the terms of the plan.’ ” Snow v. Standard Ins. Co., 87 F.3d 327, 330 (9th Cir.1996) (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956, 103 L.Ed.2d 80 (1989)). “When discretion is conferred, the exercise of that discretion is reviewed under the arbitrary or capricious standard, or for abuse of discretion, which comes to the same thing.” Id. (citing Atwood v. Newmont Gold Co., 45 F.3d 1317, 1321 & n. 1 (9th Cir.1995)). “ ‘It is an abuse of discretion for an ERISA plan administrator to make a decision without any explanation, or in a way that conflicts with the plain language of the plan, or that is based on clearly erroneous findings of fact.’ ” Id. at 331 (quoting Atwood, 45 F.3d at 1323-24). U.S. Shoe’s Plan clearly confers discretionary authority to construe the terms of the Plan upon the Benefit Committee. The Plan gives the Benefit Committee authority to “interpret and construe this Plan ... to determine all questions of eligibility ... to determine the benefits payable ... and to decide such questions as may arise in connection with the operation of this Plan.” See supra ¶ 15. Thus, if our analysis were to proceed no further, it would appear that we should apply the abuse of discretion standard, not the de novo standard. Plaintiff, however, argues that we should base our analysis on three far less deferential doctrines. The first of the three is the doctrine of contra proferentem, which can, in some circumstances, require ambiguous terms in a plan to be construed against an insurer and in favor of the insured. See Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534, 539 (9th Cir.), cert. denied, 498 U.S. 1013, 111 S.Ct. 581, 112 L.Ed.2d 587 (1990). The second is the doctrine that where the summary description of a plan differs from the plan itself, the summary description controls. See Atwood, 45 F.3d at 1321. The third is the doctrine of reasonable expectations, which requires a plan to be interpreted in accordance with the reasonable expectations of the insured where the plan is ambiguous or where exclusionary provisions in a plan are not sufficiently conspicuous. See Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382, 385-87 (9th Cir.1984). In sections that follow, we discuss each of these three doctrines in turn. We conclude, under controlling Ninth Circuit authority, that the doctrine of contra proferentem does not apply to the plan at issue here. See infra § III(C). Applying the doctrine that an SPD takes precedence over the plan itself where the two conflict, we rule that U.S. Shoe’s and Prudential’s denial of coverage on the basis that Lancaster had exhausted a 365-day limit on “Extended Convalescent Care Benefits” was invalid. See infra § 111(D)(3). In our discussion of this point, we also conclude that, to the extent that U.S. Shoe and/or Prudential may have based their denial on the belief that all of the charges by Greenridge were for room and board, the denial constituted an abuse of discretion. See infra § 111(D)(4). Finally, applying the reasonable expectations doctrine, we conclude that it was not permissible to deny Lancaster’s claim on the grounds that the Plan does not provide coverage for extended care that can be provided by unskilled personnel or that is used to merely maintain a patient’s condition. See infra § III(E). C. Contra Proferentem In some circumstances, the doctrine of contra proferentem requires ambiguities in insurance contracts to be construed against the drafter of the contract, which is normally the insurer. See, e.g., Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534, 539 (9th Cir.), cert. denied, 498 U.S. 1013, 111 S.Ct. 581, 112 L.Ed.2d 587 (1990). However, in Winters v. Costco Wholesale Corp., 49 F.3d 550, 554 (9th Cir.), cert. denied, — U.S. -, 116 S.Ct. 276, 133 L.Ed.2d 197 (1995), the Ninth Circuit held “that the rule of contra proferentem is not applicable to self-funded ERISA plans that bestow explicit discretionary authority upon an administrator to determine eligibility for benefits or to construe the terms of the plan.” (Emphasis added.) U.S. Shoe’s Plan is self-funded, and it clearly gives the Benefit Committee discretion to construe the Plan. See supra ¶¶ 4, 15. Thus, it would seem that plaintiff should have no argument that the doctrine of contra proferentem applies here. Plaintiff, however, presses an argument that it does apply. Focusing on the use of the word “explicit” by the Winters court, plaintiff contends that Winters requires a benefit plan to be especially “explicit” in granting discretionary authority to construe plan terms in order for contra proferentem not to apply to a self-funded plan. We think that plaintiff is in error. First, even if Winters does require an unusually “explicit” conferral of discretion, we believe that the benefits plan at issue here is sufficiently explicit. As stated earlier, the Plan gives the Benefit Committee the “powers ... to interpret and construe this Plan ... consistent with its terms and provisions ... to determine all questions of eligibility ... to determine the benefits payable ... and to decide such questions as may arise in connection with the operation of this Plan.” See supra ¶ 15 (emphasis added). Plaintiff emphasizes the language “consistent with its terms and' provisions,” contending that this language limits the Benefit Committee’s.authority “to interpret and construe this Plan.” However, the language “consistent with its terms and provisions” still permits the Benefit Committee to construe the meaning of ambiguous terms and provisions. Secondly, we do not agree with plaintiffs reading of Winters. We interpret Winters as holding that, at least for self-funded plans, the doctrine of contra proferentem does not apply where a plan grants the administrator the same level of discretionary authority that is sufficient for a court to conclude that the abuse of discretion standard of review applies instead of the de novo standard. The main basis for this interpretation of Winters by us is a logical one — it appears to us that the abuse of discretion standard and the doctrine of contra proferentem are wholly at odds with each other. Under the abuse of discretion standard, a court is to defer to a plan administrator’s interpretation of ambiguous plan terms. But under contra proferentem, a court is to construe ambiguous plan terms against the insurer. It seems that application of the contra proferentem doctrine does not leave much, if any, room for plan administrators to exercise discretion in interpretation of ambiguous terms. The Supreme Court held in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989), that the abuse of discretion standard applies where a plan provision gives the administrator discretionary authority to interpret the plan. In our view, it would make no sense to import into “abuse of discretion” review a principle, contra proferentem, that could threaten to render the abuse of discretion standard virtually meaningless. Moreover, as we will discuss below, there are other tools, such as the reasonable expectations doctrine, which, in appropriate circumstances, can be used to impose some limits on the plan administrator’s discretion without wholly eviscerating the abuse of discretion standard. Our conclusion that Winters, 49 F.3d at 554, does not require a plan to confer any unusually “explicit” discretionary authority on a plan administrator in order for the contra proferentem doctrine to be inapplicable also is supported by a careful examination of the development of Ninth Circuit authority dealing with the application of contra proferentem in ERISA cases. Contra proferentem in the ERISA context is discussed by three post-Firestone Ninth Circuit decisions—Winters, 49 F.3d 550; Eley v. Boeing Co., 945 F.2d 276 (9th Cir.1991); and Kunin, 910 F.2d 534. Kunin, 910 F.2d 534, is the earliest of the three cases and the most favorable for plaintiff here. Importantly, the Ninth Circuit’s decision in Kunin came after Firestone, 489 U.S. 101, 109 S.Ct. 948, was decided, but the district court decision which the Ninth Circuit reviewed was issued before Firestone. See Kunin, 910 F.2d at 537. The district court in Kunin reviewed the plan interpretations at issue under the abuse of discretion standard, because before Firestone was decided, the abuse of discretion standard was applied to all ERISA benefits plans in the Ninth Circuit, not just to those that conferred discretion on the plan administrator. See Kunin, 910 F.2d at 536-37. Kunin strongly implies that the benefits plan at issue in Kunin did not have a provision granting the administrator discretionary authority to interpret plan terms, as Kunin clearly suggests that it would have been correct for the district court to apply the de novo standard if it had reviewed the plan after Firestone. See Kunin, 910 F.2d at 537. However, in order to give the defendant the benefit of the doubt on an argument that it would have been improper for the appeals court to review the administrator’s decision using a different standard than the one used by the district court, the Kunin panel applied the abuse of discretion standard. See id. The Kunin court first held that the district court did not clearly err by concluding that the plan administrator’s denial of benefits was arbitrary, and capricious. Id. at 538. The Kunin court then held in favor of the insured on an alternative ground — the plan administrator failed to follow the doctrine of contra proferentem, which requires that ambiguous plan terms be construed in favor of the insured. Id. at 539. In reaching this conclusion, the court rejected the insurer’s argument that Firestone made the doctrine of contra proferentem inapplicable in ERISA cases. See Kunin, 910 F.2d at 540-41. The Kunin court relied on passages from Firestone to support its rejection of the insurer’s argument. However, in the cited passages, the Supreme Court explains the proper way to apply de novo review, not abuse of discretion review. See Kunin, 910 F.2d at 541. Moreover, the Kunin court never had occasion to address the logical tension inherent in applying contra proferentem to a plan that grants the administrator discretionary authority to construe plan terms, because the plan at issue in Kunin apparently did not give the administrator such authority. Because of its unusual procedural circumstances, Kunin applied abuse of discretion review to a plan that apparently did not grant the administrator discretionary interpretive authority. Thus, it is not clear that Kunin squarely supports the conclusion that it is proper to apply contra proferentem where a plan grants the administrator discretionary authority to construe the terms of the plan. There is certainly no passage in Kunin that explicitly states such a holding. In Eley, 945 F.2d at 279, the Ninth Circuit stated, in dicta, without a pinpoint citation, that “the Kunin court held that, if a term in an insurance contract is ambiguous, that term must be construed against the insurer even if the insurance contract is an ‘employee welfare benefit plan’ governed by ERISA and grants discretion to the administrator.” The Eley court, however, refused to apply the contra proferentem doctrine. The plan at issue in Eley gave the administrator discretion to construe the provisions of the plan. The reasons given by the Eley court for not applying contra proferentem, however, were that, unlike the plan in Kunin, the plan in Eley was collectively bargained and was self-funded. See Eley, 945 F.2d at 280. The plan in Winters was not collectively bargained, was self-funded, and gave the plan administrator discretion to interpret plan terms. See 49 F.3d at 554. The Winters court stated that “it is not proper to rely on [the contra proferentem ] principle where, as here, the Plan grants the fiduciary explicit discretion to interpret the Plan.” Id. The court quoted Kunin for the proposition that “contra proferentem ‘is based upon the principle of contract construction that when one party is responsible for the drafting of an instrument, absent evidence indicating the intention of the parties, any ambiguity will be resolved against the drafter.’ ” Winters, 49 F.3d at 554 (quoting Kunin, 910 F.2d at 539 (adding emphasis)). The court explained that “[t]he Plan ... states how Plan terms are to be interpreted, and the general rule of contra proferentem does not apply.” Winters, 49 F.3d at 554. In view of the history of the application of the contra proferentem doctrine to ERISA cases in the Ninth Circuit, we think that the main basis for the Winters holding was the doctrinal tension that would arise if courts applied contra proferentem to a plan containing a provision granting the administrator discretionary authority to interpret plan terms. The passages we cited from Winters were likely written to correct any incorrect impressions of the law that may have been created by the ambiguity in Kunin and the dicta in Eley. Plaintiff would have us conclude that some plans do not give the plan administrator sufficiently “explicit” discretionary authority for the plan to qualify for immunity from the doctrine of contra proferentem, but do give sufficient discretionary authority for the plan to be subject to abuse of discretion review. We think that such an interpretation would be inconsistent with the spirit of Winters, and would give undue emphasis to the word “explicit” in Winters’ statement of holding. Plaintiff’s interpretation of the law would conflict with the desire to eliminate the potential inconsistency between the doctrine of contra proferentem and abuse of discretion review that seems to us to he at the heart of Winters. We thus conclude that Winters does not require a benefits plan, in order for the doctrine of contra proferentem to be inapplicable, to give the administrator discretionary interpretive authority through language that is more explicit than the kind of language that is sufficient to qualify an ERISA plan for abuse of discretion review in the Ninth Circuit. Since we have already decided that the language in the U.S. Shoe Plan would be sufficient, absent competing considerations, to trigger abuse of discretion review, as opposed to de novo review, we hold that the doctrine of contra proferentem is inapplicable in this case. D. Conflict Between the SPD and the Plan 1. The Atwood Doctrine. Under Atwood v. Newmont Gold Co., 45 F.3d 1317, 1321 (9th Cir.1995), where an SPD and a plan conflict in their descriptions of the circumstances which may result in a denial of benefits, the SPD controls over the plan. We shall henceforth call this doctrine the “Atwood doctrine.” In Atwood, the Ninth Circuit stated that “ERISA requires that the SPD explain the ‘circumstances which may result in disqualification, ineligibility, or denial or loss of benefits.’ ” Id. (quoting 29 U.S.C. § 1022(b)). The court added that the Ninth Circuit has “interpreted § 1022(b) to mean that the SPD ‘must be specific enough to enable the ordinary employee to sense when there is a danger that benefits could be lost or diminished.’ ” Id. (quoting Stahl v. Tony’s Bldg. Materials, Inc., 875 F.2d 1404, 1408 (9th Cir.1989)). The court stated, “Where the SPD fails to meet this requirement and differs materially from the terms of the plan, the SPD is controlling.” Id. (citing Arnold v. Arrow Transp. Co. of Del., 926 F.2d 782, 785 n. 3 (9th Cir.1991)). The Ninth Circuit’s adoption of the principle that an SPD controls over a plan where the two conflict followed some vacillation about the issue on the part of the appellate court. In Arnold, 926 F.2d at 785 n. 3, the Ninth Circuit cited, with apparent approval, Edwards v. State Farm Mut. Auto Ins. Co., 851 F.2d 134, 136 (6th Cir.1988), for the proposition that “summary plan statements are binding,” and two district court cases, Kochendorfer v. Rockdale Sash & Trim Co. Profit Sharing Plan, 653 F.Supp. 612, 614 (N.D.Ill.1987), and Gors v. Venoy Palmer Market, Inc., 578 F.Supp. 365, 368 (E.D.Mich.1984), for the proposition that “challenges to a plan can be based on [a] summary plan description and such a summary may modify the terms of the plan.” However, in Long v. Flying Tiger Line, Inc. Fixed Pension Plan for Pilots, 994 F.2d 692, 695 & n. 1 (9th Cir.1993), the Ninth Circuit stated that it had not yet decided the issue of whether an SPD takes precedence over policy documents if the two conflict, and denied that Arnold had adopted the holding in Edwards, 851 F.2d at 136, that the SPD is binding on the insurer. Then, in an opinion published less than three months after Long, Price v. Provident Life & Acc., Ins. Co., 2 F.3d 986 (9th Cir.1993), the Ninth Circuit stated, in dicta in a footnote, that “the [provision at issue] is part of the plan summary, the terms of which are binding on [the insurer] and which govern if the summary conflicts with the policy.” Price, 2 F.3d at 988 n. 1 (citing Hansen v. Continental Ins. Co., 940 F.2d 971, 982 (5th Cir.1991)). Despite the Ninth Circuit’s initial vacillation, we think that the clear statement in Atwood, 45 F.3d at 1321, leaves no room for doubting that the Ninth Circuit has adopted what we call the “Atwood doctrine.” 2. Is Reliance Required Under the Atwood Doctrine? One issue that Atwood does not explicitly discuss is whether, in order for the terms of the SPD to supersede the plan under the Atwood doctrine, a plaintiff is required to show that he relied on the SPD. Other circuits have split on this issue. The Second, Fifth, and Sixth Circuits have held that reliance is not required. See Hansen, 940 F.2d at 982; Heidgerd v. Olin Corp., 906 F.2d 903, 907-08 (2d Cir.1990); Edwards, 851 F.2d at 136-37. The First, Third, Seventh, and Eleventh Circuits, on the other hand, have held that reliance is required. See Branch v. G. Bernd Co., 955 F.2d 1574, 1579 (11th Cir.1992); Senkier v. Hartford Life & Accident Ins. Co., 948 F.2d 1050-51 (7th Cir.1991); Gridley v. Cleveland Pneumatic Co., 924 F.2d 1310, 1319 n. 8 (3d Cir.), cert. denied, 501 U.S. 1232, 111 S.Ct. 2856, 115 L.Ed.2d 1023 (1991); Bachelder v. Communications Satellite Corp., 837 F.2d 519, 522-23 (1st Cir.1988). Three district court decisions within the Ninth Circuit hold that reliance is required for an SPD to take precedence over underlying plan documents. See Adams v. J.C. Penney Co., 865 F.Supp. 1454, 1459-60 (D.Or.1994), aff'd mem., 83 F.3d 426 (9th Cir.1996); Kaiser Permanente Employees Pension Plan v. Bertozzi, 849 F.Supp. 692, 698 (N.D.Cal.1994); Berry v. Blue Cross of Washington & Alaska, 815 F.Supp. 359, 364-65 (W.D.Wash.1993). However, relying mainly on authority published after these three district court decisions were issued, we respectfully disagree with the three decisions, and hold that reliance is not required under the Atwood doctrine. The first reason for our conclusion that reliance is not required under the Atwood doctrine is that the Ninth Circuit Court of Appeals decisions favoring the doctrine do not appear to support including a reliance requirement in the doctrine. Atwood, 45 F.3d at 1321, which was decided after Adams, Kaiser, and Berry, and which was the first Ninth Circuit case to clearly adopt the doctrine that an SPD takes precedence over separate policy documents, says nothing about a reliance requirement. The two earlier Ninth Circuit cases that appeared to favor the adoption of the Atwood doctrine, Price, 2 F.3d at 988 n. 1, and Arnold, 926 F.2d at 785 n. 3, also do not mention a reliance requirement. Moreover, the two cases from other circuits cited with approval by Price and Arnold for the proposition that an SPD supersedes a conflicting plan, Hansen, 940 F.2d at 982, and Edwards, 851 F.2d at 136-37, both hold that reliance is not required. The second and strongest reason supporting our conclusion that reliance is not required under the Atwood doctrine is that such a requirement would not make sense in view of the Ninth Circuit’s adoption of the reasonable expectations doctrine in Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d 382 (9th Cir.1994). Saltarelli was decided after the three district court decisions which favor a reliance requirement. The reasonable expectations doctrine requires an ERISA benefits plan to be interpreted in accordance with the reasonable expectations of the insured. See Saltarelli, 35 F.3d at 386-87. A prerequisite for application of the reasonable expectations doctrine is that the plan must be ambiguous or an exclusionary provision in the plan must not be sufficiently conspicuous. See infra § 111(E)(3); Peterson v. American Life & Health Ins. Co., 48 F.3d 404, 411 (9th Cir.), cert. denied, — U.S.-, 116 S.Ct. 377, 133 L.Ed.2d 301 (1995); Krishan v. McDonnell Douglas Corp., 873 F.Supp. 345, 353 n. 7 (C.D.Cal.1994). When there is both an SPD and separate, underlying policy documents, the authorities suggest (and we conclude below) that it is correct to examine the SPD, not the separate policy documents, in determining whether the reasonable expectations doctrine is applicable (and in applying the doctrine). See infra § III(E)(3); Saltarelli 35 F.3d at 385. The reasonable expectations doctrine examines “objectively reasonable expectations of coverage.” See Saltarelli 35 F.3d at 387 (emphasis added). There is absolutely no allusion to the insured’s actual state of mind or to “reliance” in any of the decisions by courts within the Ninth Circuit that apply or discuss the reasonable expectations doctrine. See, e.g., McClure v. Life Ins. Co. of North America, 84 F.3d 1129, 1135-36 (9th Cir.1996); Saltarelli, 35 F.3d at 385-87; Henry v. Home Ins. Co., 907 F.Supp. 1392, 1396-97 (C.D.Cal.1995). Thus, the available decisional law strongly supports a conclusion that there is no reliance element under the reasonable expectations doctrine as applied to ERISA plans by the Ninth Circuit. It would be anomalous, at best, to impose a reliance requirement under the Atwood doctrine but to impose no such requirement under the reasonable expectations doctrine. The Atwood doctrine applies where the SPD unambiguously conflicts with the plan; the reasonable expectations doctrine applies where the SPD is ambiguous or contains an insufficiently conspicuous exclusion. Certainly, courts should be more willing to disregard underlying plan documents where the plan clearly conflicts with the SPD than where the plan only conflicts with reasonable expectations based on an ambiguous SPD or where exclusions in an SPD are insufficiently prominent. Yet adopting a reliance requirement under the Atwood doctrine but not under the reasonable expectations doctrine would produce precisely the opposite result— it would become more difficult for a clear SPD to supersede a conflicting plan than for an ambiguous SPD to do the same! Ou