A recent ruling received by Bonny G. Rafel, LLC examined the recent habit of insurers tampering with the ERISA regulated mandates for deciding appeals of denied ERISA claims. We have received many letters from insurers advising us that they will not start the appeal review until we notify them that we will not be furnishing anymore medical records to them for consideration. We have always contested that unilateral roadblock to providing proof during the appeal that our clients remain disabled! The law is clear as to the obligation of the insurer to decide the appeal no later than 90 days after the submission of the appeal.
ERISA requires all employee benefits plans to “afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.” 29 U.S.C. § 1133(2). The Secretary of Labor has established regulations implementing the minimum requirements under ERISA for employee benefit plan procedures pertaining to beneficiary claims. These regulations include time limits by which an appeal of a denial of benefits must be decided. ERISA provides: “the plan administrator shall notify a claimant . . . of the plan’s benefit determination on review within a reasonable period of time, but not later than  days after receipt of the claimant’s request for review by the plan, unless the plan administrator determines that special circumstances (such as the need to hold a hearing, if the plan’s procedures provide for a hearing) require an extension of time for processing the claim. If the plan administrator determines that an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial -day period. In no event shall such extension exceed a period of  days from the end of the initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the plan expects to render the determination on review.” 29 C.F.R. § 2560.503-1(i)(1)(i) & (i)(3)(i). (emphasis added).
There is a regulation that provides a plan the right to “toll” the deadline if they request certain documentation missing from the submission. But that is not at all what happened here to our client.
Our client, Ms. Lewis-Burroughs, had suffered from Sjogren’s Syndrome, systemic lupus, fibromyalgia, polyarthopathy, and Raynaud’s Syndrome. Her claim was denied after several years of payment.
We submitted Ms. Lewis-Burroughs’s appeal by the 180 day deadline, with many exhibits, including information about an examination that Prudential had conducted of her. The appeal decision, under the above statute, was due by March 12, 2014. We supplemented the appeal several times with more information that we received after we had filed the appeal. Prudential unilaterally attempted to “toll” their appeal decision deadline, and essentially reset the clock and the 90 day period to determine her appeal for a period after we had supplemented the record. The court disagreed.
In Lewis-Burroughs v. Prudential Ins. Co. of Am., 2015 U.S. Dist. LEXIS 57584 (D.N.J. Apr. 30, 2015), the court ruled that the plaintiff, a former nurse at Newark Beth-Israel Medical Center, was entitled to sue Prudential for their failure to decide the appeal by the 90 day deadline.
The court relied on Heimeshoff v. Hartford Life & Accident Ins. Co., 134 S. Ct. 604, 612 (2013) which contends that parties are bound by the appeal process set forth in the Plan. The Plan provides that Prudential was required to decide Ms. Lewis-Burroughs’s appeal within 90 days after receipt of her appeal request. There is no dispute that Ms. Lewis-Burroughs appealed Prudential’s denial on December 12, 2013 and that the 90 day clock began to run from that date.
This seminal opinion highlights the fact that tolling cannot be used as a post hoc justification for delay; and it follows Tomassi v. Prudential Inc. Co. of America, 2007 U.S. Dist. LEXIS 44223 (N.D. Ill. June 19, 2007), which stated that “[r]estarting Prudential’s clock every time a claimant submits records would in many situations give Prudential an endless amount of time to consider appeals and might discourage claimants from submitting relevant new medical information”.
See also Gay v. Nat’l Rural Elec. Coop. Ass’n Group Benefits Program, 2014 U.S. Dist. LEXIS 153585 (S.D. Ohio Oct. 29, 2014) (carrier cannot unilaterally toll the deadline for making a benefits determination on appeal and there is no such thing as indefinite tolling).
Contact us at Bonny G. Rafel, LLC to ensure that your insurer is not abusing the process by tolling your benefits determination.