ERISA LAW BLOG

Previously, I did a video blog about the statute of limitations in ERISA cases.  Today, I wanted to provide a written blog post to further that discussion and provide some case law for Fourth Circuit practitioners.  As previously discussed, for a benefits claim, determining the statute of limitations can be a tricky subject.  However, the Code of Federal Regulations has attempted to clarify that issue for plaintiffs.  If a plan has a specific statute of limitations in it, courts across the country are ruling that, pursuant to the Code of Federal Regulations, insurers must put that statute of limitations in the final denial letter.  In 2018, I prevailed on this very issue and, the court ruled as follows:

The purpose of ERISA’s notice requirement is “to provide claimants with enough information to prepare adequately for further  administrative review or an appeal to the federal courts.” Juliano v. Health Maint. Org. of NJ, Inc., 221 F.3d 279, 287 (2d Cir. 2000) (internal quotation marks omitted).

Research revealed no Fourth Circuit case law addressing whether failure to comply with 29 C.F.R. § 2560.503-1(g)(1)(iv) and (j)(4)(i) bars enforcement of a contractual time limitation. However, other circuits have considered this issue. In Santana-Diaz v. Metropolitan Life Ins. Co., 816 F.3d 172 (1st Cir. 2016), the First Circuit considered whether § 2560.503-1(g)(1)(iv) applied to final denial letters and concluded that

a denial of benefits letter must include notice of the plan-imposed time limit for filing a civil action. To repeat, the regulation states that the letter must contain a “description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action.”

Id. at 180. Further, in Mirza v. Insurance Administrator of America, Inc., 800 F.3d 129 (3d Cir. 2015), the Third Circuit concluded that “29 C.F.R. § 2560.503-1(g)(1)(iv) requires that adverse benefit determinations set forth any plan-imposed time limit for seeking judicial review. Without this time limit, a notification is not in substantial compliance with ERISA.” Id. at 136. Likewise, in Moyer v. Metropolitan Life Insurance Co., 762 F.3d 503 (6th Cir. 2014), the Sixth Circuit concluded that § 2560.503-1(g)(1)(iv) required that “[t]he claimant’s right to bring a civil action is expressly included as a part of those procedures for which applicable time limits must be provided,” and thus held that denial letters must include the time limit for judicial review. Id. at 505.

Further, although § 2560.503-1(j)(4) does not specifically require that claimants be informed of a contractual time limitation, reading subsection (j)(4)(i) in conjunction with subsection (g)(1)(iv) requires that plan administrators disclose the voluntary internal appeal procedures and the contractual limitations period in final denial letters. Moreover, this reading is logical because the voluntary internal appeal procedures and the civil action limitations periods are the only remaining options for a claimant seeking to challenge a denial of coverage following the issuance of a final denial letter. See e.g., William v. United Healthcare, No. 1:16-CV-00144-DN, 2017 WL 2414607, at *7 (D. Utah June 2, 2017) (unpublished).  Starnes v. Universal Fidelity Administrators Company, et al., C/A No.: 6:17-3073-HMH (D.S.C. 2018).

I hope that the above case law is helpful in addressing the issue, but if you have any questions, please do not hesitate to contact me.  As always, if you are an attorney looking for help with an ERISA claim, I am happy to do what I can.

Nathaniel W. Bax, Managing Partner