This ERISA case has not been decided yet but makes an interesting argument. This is an “Amicus Curiae” (friend of the court) brief submitted by the U.S. Secretary of Labor.
The Plaintiff/Insure had received unsuccessful treatment for prostate cancer, which had left him him with a long list of medical problems. He filed a claim for long term disability with the Defendant. This claim was denied, stating that the Plaintiff had not provided enough information to show that he was unable to work. Plaintiff had 180 days to appeal this decision and sought two extensions within which to appeal. The Defendant denied the first extension and did not respond to the second, so the Plaintiff timely appealed. The Defendant then notified the Plaintiff that it had reversed its original denial but stated that this reversal did not guarantee payment of benefits. The Defendant stated that the claim department would review the submitted information and determine if the Plaintiff met the definition of disability and then render a new decision. The Defendant did not state when this would be done. The Plaintiff waited 46 days, and then filed suit under ERISA. Finally, months later, the Defendant notified the Plaintiff that it had denied his long term disability claim again. The district court dismissed the Plaintiff’s claim because it determined that the Plaintiff had not exhausted all his remedies administratively with the Defendant before resorting to the courts.
The Plaintiff argues that the Claims Procedure Regulation sets for the minimum requirements for the employee benefit plan procedures pertaining to claims for benefits. This procedure requires ERISA plans to decide benefit appeals within specified time frames. If the Defendant fails to meet these time frames, the Plaintiff is deemed to have exhausted administrative remedies and is entitled to pursue any available remedies under ERISA. The district court in this case held that the Defendant timely issued a benefit determination on review by sending the claim to its claim department. The Plaintiff argues that this is contrary to the plain language, structure and purpose of the claims-procedure regulation. The Plaintiff argues that a “benefit determination on review” requires a straight up or down decision either granting or denying benefits. The Defendant’s sending the claim to its claim department ending nothing. Further, the Plaintiff argues that the idea that plans can simply “remand” benefit appeals back to themselves without deciding whether benefits are due undermines ERISA’s goal of ensuring speedy decisions. If a “remand” qualifies as a “benefit determination on review” under ERISA, a defendant plan could repeatedly issue vacate-and-remand decisions, endlessly, without contradicting the regulations.
The U.S. Secretary of Labor issued an Amicus Curiae brief supporting the Plaintiff’s argument. It reviewed the applicable statues under ERISA for plain language and agreed with the Plaintiff’s assertions. The Secretary ends its brief by requesting that the Court reverse the lower court’s dismissal of the Plaintiff’s claims. Stay tuned for the result.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.