Archives: Exhaustion of Administrative Remedies

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Where Administrative Appeal Deadline Ends on Saturday, Monday Appeal Is Timely

In LeGras v. Aetna Life Ins. Co., 786 F.3d 1233 (9th Cir. 2015), plaintiff’s 180-day period to administratively appeal ended on a Saturday, and he mailed his appeal the following Monday. Aetna denied the appeal as untimely. Plaintiff sued, and the district court had dismissed the claim for failure to exhaust administrative remedies. The 9th … Continue Reading

Failure to Understand Exhaustion Requirement Does Not Excuse Compliance

Orr v. Assurant Employee Benefits, 786 F.3d 596 (7th Cir. 2015), concerned the failure to exhaust administrative remedies following the denial of a claim for AD&D benefits. The plan in question required two administrative appeals; the administrator advised plaintiffs of these two appeals, and specifically stated that the failure to complete both reviews could result … Continue Reading

ERISA Claim Accrues Upon Clear Repudiation of Claim, Even if There is No Formal Denial Letter

In Witt v. Metro. Life Ins. Co., 772 F.3d 1269 (11th Cir. 2014), the court answered the question: “what happens when the defendant says it issued a formal denial letter and the plaintiff says he never received the letter, but it is undisputed the defendant terminated benefits and did not pay the plaintiff any benefits … Continue Reading

Heimeshoff v. Hartford Life: Supreme Court Holds that Plan Can Start Limitation Clock Before Benefit Claim Accrues

In Heimeshoff v. Hartford Life & Acc. Ins. Co., 571 U.S. __ (Dec. 16, 2013) , the Supreme Court held that a contractual limitation provision under which the clock begins to run before administrative remedies are exhausted  is enforceable under ERISA, as long as a reasonable time is left after exhaustion is expected to occur. … Continue Reading

Heimeshoff v. Hartford – Supreme Court Briefing

In petitioning for certiorari, Heimeshoff asked the Supreme Court to consider three questions: 1.         When should a statute of limitations accrue for judicial review of an ERISA disability adverse benefit determination? 2.         What notice regarding time limits for judicial review of an adverse benefit determination should an ERISA plan or its fiduciary give the claimant … Continue Reading

Heimeshoff v. Hartford – Motion to Dismiss

Hartford moved to dismiss the action because it was filed after the expiration of the policy’s contractual limitation period. The plain language of the Policy gave her until December 8, 2005 to submit proof of loss: she alleged that her disability began on June 6, 2005; the ninety-day Elimination Period would ordinarily end on September … Continue Reading

Sixth Circuit Explains Why SPD is Still Important After Amara

In 2011, the Supreme Court clearly held that a summary plan description cannot trump the terms of an ERISA plan, overturning the rule in many circuits. Instead, the Amara rule provides that the plan itself governs over a summary of the plan when the two conflict. This does not mean that an SPD is meaningless. … Continue Reading

Including Ambiguous Plan Language Verbatim In the SPD Can Effectively Eliminate Discretion to Interpret It — At Least in the Fifth Circuit

In Koehler v. Aetna Health, Inc., 683 F.3d 182 (5th Cir. 2012), the Fifth Circuit criticized a health insurer for having an SPD that mirrored the plan, and held that Cigna v. Amara did not prevent the terms of the SPD from impacting plan interpretation. The plaintiff, a participant in an HMO, suffered from sleep … Continue Reading

Failure to Exhaust Administrative Remedies Not Excused Even When Termination Notice Is Defective

In Schorsch v. Reliance Standard Life Ins. Co., — F.3d — ,  2012 WL 3667977 (7th Cir. Aug. 28, 2012), the court “considered here whether the content of a termination notice, specifically the absence of particular information, caused the beneficiary’s failure to exhaust and whether [he is]  estopped from taking advantage of that failure.” The … Continue Reading
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