Does your ERISA claim benefit denial letter preserve the contractual limitations defense?
If your denial letter fails to expressly state the contractual limitations timeframe, it might not preserve that defense.
Here’s the case of Moyer v. Met Life Ins. Co., __ F.3d __ (6th Cir. August 7 2014)(2-1 decision).
FACTS. Moyer made a claim in 2005 for disability under an ERISA-governed Long Term Disability Plan. The plan had a contractual limitation provision which states: “[n]o lawsuit may be started more than 3 years after the time proof [of a claim] must be given.” Met Life initially approved the claim. In 2007, Met Life determined Moyer could perform work in “any occupation.” Met Life denied the appeal on June 20, 2008. The denial letter included notice of the right to judicial review, but did not expressly state that a three year contractual time limit applied. Moyer sued Met Life on February 20, 2012.
DISTRICT COURT HELD: Case dismissed because the plan contained a three-year limitations period for filing suit. The Plan provided constructive notice of the time limit.
SIXTH CIRCUIT HELD: REVERSED (SPLIT DECISION)
29 C.F.R. Section 2560.503-1 requires ERISA-governed denial letters to provide “the time limits applicable to [the plan’s review procedures], including a statement of the claimant’s right to bring a civil action….” Op. at 4 (Emphasis in original).
The applicable time limits for bringing a civil action “must be provided” in the benefit determination letter. Id.
The “failure to include the judicial review time limits in the adverse benefit determination letter renders the letter not in substantial compliance with [ERISA] Section 1133.” Op. at 5.
DISSENT. “Ample authority counsels against the majority’s approach.” Dissent at 8.
DISSENT. “[C]ourts elsewhere split on whether the regulation requires a claim-denial letter to inform a plan participant of both their right to bring a civil action and the action’s limitations period. [T]he purpose of Section 1133 is limited to assuring review by the plan fiduciary.” Dissent at 9 (Emphasis in original and cases cited.)
DISSENT. “The majority gives short shrift to the ‘substantial compliance’ test.” Dissent at 9.