Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_07-cv-04696/USCOURTS-cand-3_07-cv-04696-2/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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United States District Court

For the Northern District of California

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

MARK EPPLER, an individual,

Plaintiff,

 v.

HARTFORD LIFE AND ACCIDENT

INSURANCE COMPANY, LONG

TERM DISABILITY AND LIFE PLAN

FOR EMPLOYEES OF MINNESOTA

METHANE LLC,

Defendants. /

No. C 07-04696 WHA

ORDER DENYING

DEFENDANTS’ MOTION FOR

SUMMARY JUDGMENT

INTRODUCTION

In this disability-benefits action, plaintiff Mark Eppler is suing defendant Hartford Life

and Accident Insurance Company and defendant Long Term Disability and Life Plan for

Employees of Minnesota Methane, LLC, for wrongful termination of disability benefits. 

Defendants now move for summary judgment on the ground that plaintiff failed to exhaust his

administrative remedies before filing suit under the Employment Retirement Income Security

Act of 1974, 29 U.S.C. 1001 et seq. The motion for summary judgment is DENIED.

STATEMENT

The following facts are undisputed. Plaintiff was employed as a company controller by

Minnesota Methane LLC. He also participated in an employee welfare-benefit plan governed by

ERISA. The plan designated Hartford as the claims fiduciary. Hartford was responsible for

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 The plan’s provisions regarding appeals is in accordance with 29 C.F.R. 2560.503-1(h)(3):

“Group health plans. The claims procedures of a group health plan will not be deemed to provide a claimant

with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless,

in addition to complying with the requirements of paragraphs (h)(2)(ii) through (iv) of this section, the claims

procedures — (i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit

determination within which to appeal the determination; (ii) Provide for a review that does not afford deference

to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan

who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor

the subordinate of such individual; (iii) Provide that, in deciding an appeal of any adverse benefit determination

that is based in whole or in part on a medical judgment, including determinations with regard to whether a

particular treatment, drug, or other item is experimental, investigational, or not medically necessary or

2

interpreting the policy and determining eligibility for benefits. In part, the plan stated (Anderson

Decl. Exh. 1 at E680–81):

Appealing Denials of Claims for Benefits

On any wholly or partially denied claim, you or your representative

must appeal once to the Insurance Company for a full and fair

review. You must complete this claim appeal process before you

file an action in court. Your appeal request must be in writing and

be received by the Insurance Company no later than the expiration

of 180 days from the date you received your claim denial. As part

of your appeal:

1. You may request, free of charge, copies of all documents,

records, and other information relevant to your claim; and

2. You may submit written comments, documents, records and

other information relating to your claim.

The Insurance Company’s review on appeal shall take into account

all comments, documents, records and other information submitted

by you relating to the claim, without regard to whether such

information was submitted or considered in the initial benefit

determination. 

The Insurance Company will make a final decision no more than 45

days after it receives your timely appeal. The time for final

decision may be extended for one additional 45 period provided

that, prior to the extension, the Insurance Company notifies you in

writing that an extension is necessary due to special circumstances,

identifies those circumstances and gives the date by which it

expects to render its decision. If your claim is extended due to your

failure to submit information necessary to decide your claim on

appeal, the time for decision shall be tolled from the date on which

the notification of the extension is sent to you until the date we

receive your response to the request.

The individual reviewing your appeal shall give no deference to the

initial benefit decision and shall be an individual who is neither the

individual who made the initial benefit decision, nor the subordinate

of such individual.1

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appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate

training and experience in the field of medicine involved in the medical judgment; (iv) Provide for the

identification of medical or vocational experts whose advice was obtained on behalf of the plan in connection

with a claimant's adverse benefit determination, without regard to whether the advice was relied upon in making

the benefit determination; (v) Provide that the health care professional engaged for purposes of a consultation

under paragraph (h)(3)(iii) of this section shall be an individual who is neither an individual who was consulted

in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any

such individual . . .” .

3

 Plaintiff claimed to suffer from a severe form of sleep apnea with hypersomnia. 

Whether he was really ill is disputed. On October 29, 2003, he stopped working, claiming sleep

deprivation, fatigue, and the inability to think, concentrate, and stay awake. Hartford approved

his claim for short-term disability benefits for October 30, 2003, through November 11, 2003,

and for long-term benefits from April 29, 2004, through April 29, 2006. To continue,

plaintiff had to be considered “Totally Disabled.”

In a letter to plaintiff dated April 28, 2006, Hartford stated that it had determined that

the evidence submitted in support of plaintiff’s claim did not establish that plaintiff continued

to meet the policy definition of “disability” or “disabled.” The letter defined relevant terms

and included where they could be found in the Minnesota Methane LLC’s LTD plan booklet

for Policy GLT 302812. In addition, it quoted the part of the policy stating that benefit payments

terminated on the date claimants were no longer “disabled” as defined. Twenty-two sources —

including questionnaires, medical records, and surveillance videos — were listed,

constituting the record upon which the decision was based. The letter described in further detail

what was observed (Anderson Decl. Exh. 2 at E165–72): 

To clarify your abilities and restrictions, video surveillance was

conducted. Surveillance was conducted initially on August 6 and

August 7, 2006. On August 6 you were not observed. On August 7

you were active for approximately 4 hours. During this time you

were observed going to a baseball game, a department store,

and back to your residence where you did yard work briefly. 

Additional surveillance was conducted on September 20 and 21,

2005. On September 20, you were not observed. On September 21

you departed driving your vehicle and returning to your residence

approximately one hour later. A final round of surveillance was

conducted on November 6 and November 7, 2005. On November 6

you were away from your residence for approximately 6 hours and

50 minutes. On this date you were observed going to a baseball

game. While at the game you were observed standing, walking,

briefly jogging, bending, catching a baseball, and pulling a bag.

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During the periods of surveillance you were observed walking at a

brisk pace, driving, getting in and out of a truck, walking down

steps without the use of an available railing, carrying a bag of

baseballs in both hands, pulling an athletic bag on wheels, placing

most of your weight on each leg, bending at the waist, continuously

on your feet for at least 34 minutes at a time, sitting continuously

for 34 minutes at a time, and reaching in all directions. When

observed you demonstrated no sign of difficulty or hesitation while

performing the activities. Your observed activities were

inconsistent with your reports that you experience excessive

daytime sleepiness resulting in constant fatigue, inability to

concentrate or focus.

The claim file was reviewed by a medical case manager, who sent plaintiff’s physicians the

results of the surveillance and claimant interview with a Hartford investigator: “On April 22,

2006, the Medical Case Manager received a response from Dr. Gannon [plaintiff’s doctor]. 

Dr. Gannon indicated that he agreed that you were not precluded from performing a full time

sedentary to light occupation that allowed position changes as needed” (ibid.). The other

physicians deferred to Dr. Gannon’s opinion. The letter concluded with (emphasis added): 

The Employee Retirement Income Security Act of 1974 (ERISA)

gives you the right to appeal our decision and receive a full and

fair review. You may appeal our decision even if you do not have

new information to send us. You are entitled to receive, upon

request and free of charge, reasonable access to, and copies of, all

documents, records and other information relevant to your claim. 

If you do not agree with our denial, in whole or in part, and you

wish to appeal our decision, you or your authorized representative

must write to us within one hundred eighty (180) days from your

receipt of this letter. Your appeal letter should be signed, dated

and clearly state your position. Along with your appeal letter, you

may submit written comments, documents, records and other

information related to your claim.

Once we receive your appeal, we will again review your entire

claim, including any information previously submitted and any

additional information received with your appeal. Upon

completion of this review, we will advise you of our

determination. After your appeal, and if we again deny your

claim, you then have the right to bring a civil action under Section

502(a) of ERISA

Assuming the April 28 letter started the 180-day appeal clock (discussed below), plaintiff had

until October 25, 2006, to appeal the decision.

Significantly, more than five months went by with no action by plaintiff, i.e., of the

180-day period, all but three weeks went unused with no communication by plaintiff. His

counsel then sent a letter to Hartford dated October 3, 2006. Counsel wrote, “Mr. Eppler wishes

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to appeal The Hartford’s decision. In order to permit him to do so, and to respond adequately to

The Hartford’s decision, we respectfully request that you provide to us the following documents

and information . . .” The letter further stated, “We also respectfully request that you inform us

of any particular additional information or records which you consider necessary to perfect

Mr. Eppler’s claim for benefits” (id. at E162–63). One of the issues presented is whether this

constituted an appeal (as opposed to a statement of an expectation of future appeal).

Hartford responded by letter dated October 9, 2006. It acknowledged receipt of

plaintiff’s request. It also forwarded plaintiff’s request for more documents to the company

claim office. In the October 9 correspondence, Hartford wrote, “When your appeal is complete

please send it to the following address: [address for Disability Claim Appeal Unit]. Please note

that the complete appeal must be submitted to us by December 4, 2006” (id. at E133.C). The

October 9 letter thus unilaterally extended the due date for appeal by 40 days. On October 23,

2006, Hartford notified plaintiff that he was “entitled to receive a copy of the complete

administrative record. Enclosed you will find a complete copy of your client’s claim file as well

as a copy of the Booklet-certificate, the surveillance, and the Summary Detail Report. The

enclosed comprises the complete administrative record” (id. at E133). In short, five months of

the 180-day period went by with no action by anyone and then in the last month of the appeal

period, plaintiff’s counsel sent a letter asking for documents to review for use in an appeal. 

Hartford sent documents in reply and gave an extension to December 4 to make the appeal.

The following fact is disputed. Plaintiff claims that his counsel wrote to Hartford on

November 30, 2006. In a letter nearly identical to the one dated October 3, plaintiff's counsel

wrote, “Thank you for your letter dated October 23, 2006, enclosing some, but not all of the

documents and information requested in my letter dated October 4, 2006 [sic]. In order to permit

Mr. Eppler to respond adequately to The Hartford’s decision, we respectfully request once again

that you provide to us the following documents and information . . .” The letter further asked

“that you inform us of any particular additional information or records which you consider

necessary to perfect Mr. Eppler’s claims for benefits. Once we have all of the requested

documentation and information, we intend to have them reviewed by Mr. Eppler’s physicians

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and/or an independent physician for evaluation and response” (Fannon Decl. Exh. 5). At the

hearing on February 7, 2008, plaintiff’s counsel swore under oath that he personally had written

and sent the November 30 letter to defendants. 

Defendants, on the other hand, assert that Hartford did not receive the November 30 letter

or any further correspondence from plaintiff. Todd Andersen, Long-Term Disability Team

Leader in Hartford’s Minneapolis Disability Claim Office ,stated in his sworn declaration that

the processing of outside mail included summarizing the information in electronic summary

detail reports. All claim-related communications within the company and from or to individuals

outside the company (verbal or written) were reflected in these reports. For December 4, 2006,

the summary detail report stated only one line, indicating that Hartford had never received an

appeal from plaintiff and the claim file was therefore closed: “took off diary. appeal was not

submitted.” No other activity was recorded in the summary detail report between October 23

and December 4, 2006 (Anderson Decl. Exh. 2 at E001–002). Furthermore, defendants allege

that it was at the joint case management conference on December 13, 2007, that plaintiff’s

counsel “asserted for the first time that he had sent a letter to The Hartford dated November 30,

2006 . . . As discussed in the accompanying Swanson and Anderson declarations, this letter was

never received by The Hartford” (Fannon Decl. ¶ 3).

Plaintiff filed suit on September 12, 2007. He sought long-term disability benefits

allegedly due under the ERISA plan and damages resulting from breach of fiduciary duty and

statutory penalties. After the litigation had begun, plaintiff’s counsel further claimed that a

medical report had been sent to Hartford to support plaintiff’s appeal. In late November 2007,

plaintiffs’ counsel forwarded to defendants a copy of the medical report, dated July 7, 2007,

by Dr. Thomas Lewis concluding that plaintiff was disabled by fatigue, daytime somnolence,

and cognitive impairment as a result of sleep apnea. Plaintiffs counsel also forwarded a copy of

a cover letter to Hartford, which purported to include a copy of Dr. Lewis’s report. The cover

letter was dated August 2, 2007 (Fannon Decl. ¶ 2, Exh. 3 and 4). There is also a factual dispute

as to whether the August 2 letter was ever sent.

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28 2

 Unless indicated otherwise, internal citations are omitted from all cites.

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In summary, Hartford sent a denial-of-benefits letter to plaintiff on April 28. Over five

months later, plaintiff’s counsel sent a letter dated October 3 to Hartford stating that

claimant “wishes to appeal The Hartford’s decision” and requesting further information. 

Hartford responded on October 9, acknowledging receipt of plaintiff’s request, forwarding the

request to its claims department, and extending the appeal deadline from October 25 to

December 4. The administrative record was sent to plaintiff on October 23. It is disputed as to

whether or not plaintiff sent a letter on November 30, asking for more documents and

information. Asserting that it had not yet received an appeal, Hartford closed the claim file on

December 4. 

Prior to the hearing on defendants’ motion for summary judgment, the Court requested

that both parties be prepared to address the following questions: whether claims manuals were

considered during the process of denying benefits to claimants; whether there should be a tolling

of the appeal period; whether there was any sworn testimony in the record showing that the

November 30 letter had in fact been sent; and whether a notice of “intent to appeal” without a

subsequent “appeal” was sufficient to at least require a second new review and decision on a

de novo basis.

ANALYSIS

Summary judgment is granted when “the pleadings, depositions, answers to

interrogatories, and admissions on file, together with the affidavits, if any, show that there is no

genuine issue as to any material fact and that the moving party is entitled to a judgment as a

matter of law.” FRCP 56(c). A district court must determine, viewing the evidence in the light

most favorable to the nonmoving party, whether there is any genuine issue of material fact. 

Giles v. General Motors Acceptance Corp., 494 F.3d 865, 873 (9th Cir. 2007). A genuine issue

of fact is one that could reasonably be resolved based on the factual record in favor of either

party. A dispute is “material” only if it could affect the outcome of the suit under the governing

law. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248–49 (1986).2

The moving party “has both the initial burden of production and the ultimate burden of

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persuasion on a motion for summary judgment.” Nissan Fire & Marine Ins. Co., Ltd. v. Fritz

Cos., Inc., 210 F. 3d 1099, 1102 (9th Cir. 2000). When the moving party meets its initial burden,

the burden then shifts to the party opposing judgment to “go beyond the pleadings and by [its]

own affidavits, or by the depositions, answers to interrogatories, and admissions on file,

designate specific facts showing that there is a genuine issue for trial.” Celotex Corp. v. Catrett,

477 U.S. 317, 324 (1986).

Defendants claim that plaintiff failed to exhaust his administrative remedies and therefore

waived the right to pursue his claims against defendants. The Ninth Circuit enforces the

exhaustion doctrine. According to Amato v. Bernard, 618 F.2d 559, 566–67 (9th Cir. 1980), “[i]t

is true that the text of ERISA nowhere mentions the exhaustion doctrine . . . [W]e conclude from

both the legislative history and the text of ERISA that Congress did intend to grant such

authority to the courts, and that sound policy requires the application of the exhaustion doctrine

in suits under the Act.” There are two exceptions to the exhaustion requirement: if the

“administrative route is futile or the remedy inadequate.” Id. at 568.

If a plaintiff has failed to exhaust his administrative remedies and does not fall under

one of the exceptions, he may be precluded from filing suit in district court. In Diaz v. United

Agricultural Employee Welfare Benefit Plan and Trust, 50 F.3d 1478 (9th Cir. 1995),

a non-English speaking plan participant sued for benefits assertedly owed under ERISA. He

read portions of the summary plan description in Spanish, which included a description of claim

procedures. The plan later denied the participant’s claim for his daughter’s medical expenses. 

Although the text of each of the plan’s several denial letters was entirely in English, the back of

each letter contained the following notice in English and Spanish: “Appeal Rights — If you

believe your claim has not been paid correctly, you may send a written appeal within 60 days of

the date of this notice. Any written appeal should include member’s name and social security

number, the claim number, the reason for your appeal and any other information you feel might

help us in reviewing your claim. Appeal should be mailed to the address below: [address of

benefits administrator].” 

Even though the participant understood that his claim for his daughter’s expenses was

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being denied, he never took an appeal in the manner explained in the summary plan description

and the plan’s denial-of-benefit letters. Id. at 1482. The Ninth Circuit held, “By not submitting

a written appeal to the Benefits Administrator, [the plan participant] failed to comply with the

Plan’s internal review procedures and hence did not exhaust the available administrative

remedies.” Id. at 1483. The court of appeals affirmed the district court’s decision to grant the

defendants’ motions for summary judgment. Failure to properly exhaust administrative remedies

can bar a claimant from filing suit in district court.

1. WAS THE DENIAL LETTER DATED APRIL 28, 2006, DEFECTIVE?

Here, Hartford sent to plaintiff a letter dated April 28, 2006, stating in relevant part,

“If you do not agree with our denial, in whole or in part, and you wish to appeal our decision,

you or your authorized representative must write to us within one hundred eighty (180) days

from your receipt of this letter” (Anderson Decl. Exh. 2 at E71). According to defendants, this

letter triggered a contractual 180-day limitations period.

On the other hand, plaintiff argues that the denial letter was defective, as a matter of law,

to trigger any appeal deadline. In White v. Jacobs Eng’g Group Long Term Disability Benefit

Plan 896 F.2d 344, 350–51 (9th Cir. 1990), a termination notice did not trigger the time bar for

a former employee to contest the denial of his benefits under a group long-term disability plan,

where the termination notice did not adequately meet statutory and regulatory requirements of

specificity. See also Chuck v. Hewlett Packard Co., 455 F.3d 1026 (9th Cir. 2006). 

Under 29 C.F.R. 2560.503-1(g)(1), “[t]he notification [of any adverse benefit determination]

shall set forth, in a manner calculated to be understood by the claimant . . . (iii) A description of

any additional material or information necessary for the claimant to perfect the claim and an

explanation of why such material or information is necessary.” The Ninth Circuit, plaintiff

argues, has taken pains to point out this particular requirement of ERISA — “we interpreted the

ERISA regulations as calling for a ‘meaningful dialogue’ between claims administrator and

beneficiary. In resolving [the beneficiary’s] claim for benefits, [the plan’s insurer and claims

administrator] was required to give her ‘[a] description of any additional material or information’

that was ‘necessary’ for her to ‘perfect the claim,’ and to do so ‘in a manner calculated to be

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understood by the claimant.’” Saffon v. Wells Fargo & Co. Long Term Disability Plan, 2008 WL

80704, *5 (9th Cir. 2008). 

The April 28 letter fell short of this standard, plaintiff says. The letter only stated that

plaintiff “submit written comments, documents, records and other information related to your

claim” (Anderson Decl. Exh. 2 at E171). In addition, Hartford’s October 23 letter only enclosed

some, but not all, of the requested documents and information. This follow-up letter failed to

respond to plaintiff’s request as to how to perfect his claim, it is alleged.

This order disagrees. According to the Ninth Circuit, a denial letter must satisfy the

“common sense” requirement that plan administrators engage in “meaningful dialogue” with

claimants about the reasons for denying their claims. Booton v. Lockheed Med. Benefit Plan,

110 F.3d 1461, 1463 (9th Cir. 1997). This order holds that the April 28 letter did just that. 

It was eight pages and single spaced, in sharp contrast to the ones criticized in White, Chuck,

and Saffron. In reasonably clear language, Hartford advised plaintiff of the basis of the denial

and of his rights. Hartford’s conduct complied with the common-sense standard required by the

Ninth Circuit in Booton.

The April 28 letter was valid under 29 C.F.R. 2560.503-1(g) and (h), which set forth the

minimum requirements needed in a denial letter (see note 1, supra). According to the current

version of the federal regulation governing ERISA claims, 29 C.F.R 2560.503-1(g), the plan

administrator must provide a claimant with notice of any adverse benefit determination. 

The notification should set forth in relevant part:

(i) The specific reason or reasons for the adverse determination;

(ii) Reference to the specific plan provisions on which the

determination is based;

(iii) A description of any additional material or information

necessary for the claimant to perfect the claim and an explanation

of why such material or information is necessary;

(iv) 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 under section 502(a) of the

Act following an adverse benefit determination on review; 

(v) In the case of an adverse benefit determination by a group health

plan or a plan providing disability benefits,

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(A) If an internal rule, guideline, protocol, or other similar criterion

was relied upon in making the adverse determination, either the

specific rule, guideline, protocol, or other similar criterion; or a

statement that such a rule, guideline, protocol, or other similar

criterion was relied upon in making the adverse determination and

that a copy of such rule, guideline, protocol, or other criterion will

be provided free of charge to the claimant upon request.

* * *

Here, the April 28 letter stated the specific reasons for the adverse determination. It

listed 22 documents upon which the termination decision was based — e.g., medical records,

pharmacy records, and surveillance videotapes. The letter described in further detail what was

observed, such as plaintiff walking “at a brisk pace” and being active. Plaintiff’s own doctor

indicated that plaintiff could potentially perform a “full time sedentary to light occupation that

allowed position changes as needed.”

The April 28 letter also referred to the specific plan provisions on which the

determination was based: “We have completed our review of your claim for benefits and have

determined that the evidence submitted in support of your claim does not establish that you

continue to meet the Policy definition of Disability or Disabled as defined in your policy as of

April 29, 2006.” The letter then pointed to page 27 of the Minnesota Methane LLC’s LTD plan

booklet for Policy GLT 302812, which defined “Disability” or “Disabled.” All other relevant

definitions were recopied into the letter. Page 17 of the plan booklet was referenced as

explaining when benefit payments will terminate: “We will terminate benefit payment on . . .

[t]he date you are no longer Disabled as defined . . .” (Anderson Decl. Exh. 2 at E165–66).

This letter provided plaintiff with a description of any information necessary to perfect

the claim. The letter concluded by saying, “You may appeal our decision even if you do not have

new information to send us . . . You may submit written comments, documents, records and

other information related to your claim” (id. at E171). Because plaintiff did not need to send any

additional material or information in order to perfect his claim, Hartford did not need to explain

what further information was needed. Even if plaintiff wanted to send additional information,

it was encompassed in the “written comments” sentence — which was virtually identical to the

language in 29 C.F.R. 2560-503(h)(ii): “claimants [should have] the opportunity to submit

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 In White, the regulations required plan administrators to “provide to every claimant who is denied a

claim for benefits written notice setting forth in a manner calculated to be understood by the claimant: (1) The

specific reason or reasons for the denial; (2) Specific reference to pertinent plan provisions on which the denial

is based; (3) A description of any additional material or information necessary for the claimant to perfect the

claim and an explanation of why such material or information is necessary; and (4) Appropriate information as

to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review.” The

defendant in White failed to satisfy the first three requirements. The letters “offered only a conclusion that [the

claimant] had been gainfully employed, citing no reasons or evidence other than ‘information’ in [the

defendant’s] files. Several courts have held that such conclusory statements regarding a claimant’s ineligibility

for benefits do not satisfy the notice requirements.” White, 896 F.2d at 349. 

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written comments, documents, records, and other information relating to the claim for benefits.” 

The rest of the April 28 letter fulfilled the review-description requirement. It explained

that a claimant must appeal a denial of benefits within 180 days of his receipt of the letter. 

It then described the procedures for review and, in the event of another denial, for the claimant’s

right to bring a civil action pursuant to Section 502(a) of ERISA.

The April 28 notice in this case is distinguishable from the letters sent in White, Chuck,

and Saffon. In White, the letter lacked three of the four requirements of the then-applicable

regulations governing ERISA claims, 29 C.F.R. 2560.503-1(f).3

 The letter in Chuck,

which contained only one line regarding the denial of benefits, was similarly insufficient. 

“[H]ere we find it plain that [defendant] came nowhere close to complying. The only evidence

that [defendant] met any of these [notice] obligations is its letter dated January 28, 1981,

which informed [plaintiff] that his ‘vested interest has been changed due to the fact that from

September, 1972 to August, 1974 [plaintiff was] not an HP employee.’ This statement complies

with the requirement that the Plan communicate the specific reason for the denial, but it clearly

does not meet the Plan’s other obligations under [ERISA or 29 C.F.R. 2560.503-1(f)].” 

Chuck, 455 F.3d at 1032.

In Saffon, the claimant received a denial letter that stated, “The medical information

provided no longer provides evidence of disability that would prevent you from performing your

job or occupation. You no longer meet the definition of disability therefore your claim has been

withdrawn . . .” It further advised claimant that she could appeal the decision by providing

“medical evidence from the doctor(s) treating you for a condition that indicates you are under the

appropriate care and treatment and objective medical information to support your inability to

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perform the duties of your occupation.” Saffon, 2008 WL 80704 at *4. The Ninth Circuit

described the letter as “uninformative.” “[It] does not explain why [the medical information

provided offers no evidence of disability] . . . The termination letter does suggest [claimant] can

appeal by providing ‘objective medical information to support [her] inability to perform the

duties of [her] occupation,’ but does not explain why the information [claimant] has already

provided is insufficient for that purpose.” Id. at *6. In the instant case, however, the April 28

letter was much more detailed. It properly triggered the 180-day appeal period.

2. SHOULD THE 180-DAY APPEAL PERIOD HAVE BEEN TOLLED?

Plaintiff next argues, in effect, that the appeal period should be deemed tolled due

to defendants’ alleged failure to produce requested documents. As stated, the denial letter

dated April 28 was not defective. Of course, Hartford extended the due date by 40 days,

to December 4, when it produced a stack of documents in response to the October 3 letter. 

This order holds that no further tolling was necessary.

Under 29 C.F.R. 2560.503-1(h)(2), “the claims procedures of a plan will not be deemed

to provide a claimant with a reasonable opportunity for a full and fair review of a claim and

adverse benefit determination unless the claims procedures . . . (iii) Provide that a claimant shall

be provided, upon request and free of charge, reasonable access to, and copies of, all documents,

records, and other information relevant to the claimant’s claim for benefits. Whether a

document, record, or other information is relevant to a claim for benefits shall be determined by

reference to paragraph (m)(8) of this section.” Specifically, paragraph (m)(8)(ii) provides that

the document is “relevant” if it “[w]as submitted, considered, or generated in the course of

making the benefit determination, without regard to whether such document, record or other

information was relied upon in making the benefit determination.” Paragraph (m)(8)(iv) further

states that a document is relevant if, “[i]n the case of a group health plan or a plan providing

disability benefits, constitutes a statement of policy or guidance with respect to the plan

concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to

whether such advice or statement was relied upon in making the benefit determination.” 

Plaintiff alleges that Hartford did not send him some relevant documents and that the 180-day

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4

 Since the hearing set for February 7, 2008, defendants have provided the declaration of

Timothy Scully, the investigation specialist who wrote the April 28 denial letter. Mr. Sculley states, “I recall

Mr. Eppler’s claim; however, I do not recall ever having consulted, referred to, or relied upon the manual in

handling and investigating Mr. Eppler’s claim. I typically consulted the manual only on a specific, as-needed

basis for claims involving unusual circumstances, and this was not such a claim” (Scully Decl. ¶ 3). Because

the claims manual was irrelevant, defendants were therefore under no obligation to produce it.

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appeal clock should be tolled.

Tolling is an equitable doctrine. “Equitable tolling is appropriate where there is

‘excusable ignorance of the limitations period and [a] lack of prejudice to the defendant,’

or where ‘the danger of prejudice to the defendant is absent, and the interest of justice

[require relief].” Forester v. Chertoff, 500 F.3d 920, 930 (9th Cir. 2007).

This order examines the equities to determine whether or not tolling applies. The

equities work against plaintiff in the instant action. First, plaintiff let almost all of the 180 days

glide by in silence. Only near the eleventh hour did he request further information from

Hartford. Second, Hartford provided a stack of materials and extended the appeal deadline to

December 4, 2006. Plaintiff then let the rest of October and November go by without any action. 

Even crediting the story that his counsel mailed a further letter on November 30, the supposed

letter did not zero in on any specific shortfalls in the stack of documents earlier provided. 

Instead it merely requested almost verbatim the same list of documents requested the first time. 

Put differently, instead of trying to isolate any specifics still needed for an appeal, plaintiff’s

counsel merely re-demanded the same long list of materials and did so only four days before the

deadline, as extended. Counsel clearly did not take the time and trouble to review the materials

received and tailor his request to any specific items still needed. Exactly what else counsel was

requesting was not clear. Indeed, it is only from plaintiff’s opposition brief that we now know

he still seeks the Summary Plan Description and Hartford’s claims manual.4

 Both sides owe

each other a dialogue in this process but plaintiff’s counsel’s contribution was singularly

unhelpful, assuming the letter was sent at all. Third, there is no showing that plaintiff was

prejudiced in any way. He gives no reason why he needed these materials or how the lack

thereof disadvantaged his claims; he only argues that federal regulations require Hartford to

produce certain documents, and Hartford failed to do so. Hartford, on the other hand, had

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provided plaintiff with abundant notice as to the basis of the denial — with its eight-paged,

single-spaced detailed denial letter, a complete copy of plaintiff’s claim file, a copy of the

booklet-certificate, the surveillance, and summary detail report. Plaintiff had no excusable delay

and was not prejudiced. He was not entitled to any tolling.

3. DID THE OCTOBER 3 LETTER CONSTITUTE AN APPEAL?

This order holds that plaintiff’s October 3 letter should have been treated as an appeal

once the appeal period expired. The second paragraph stated, “Mr. Eppler wishes to appeal The

Hartford’s decision. In order to permit him to do so, and to respond adequately to The

Hartford’s decision, we respectfully request that you provide to us the following documents and

information . . .” (Anderson Decl. Exh. 2 at E162). Hartford was put on notice that plaintiff

wished to appeal. Under the plan, Hartford owed plaintiff the duty to make a second,

independent review, even if it were based on the same record with no new submissions. 

The plan stated, “The Insurance Company’s review shall take into account all comments,

documents, records and other information submitted by you relating to the claim, without regard

to whether such information was submitted or considered in the initial benefit determination . . . 

The individual reviewing your appeal shall give no deference to the initial benefit decision and

shall be an individual who is neither the individual who made the initial benefit decision, nor the

subordinate of such individual” (Anderson Decl. Exh. 1 at E680–81).

The appeal request did not need to be detailed. According to the plan, “Your appeal

request must be in writing and be received by the Insurance Company no later than the

expiration of 180 days from the date you received your claim denial. As part of your appeal . . .

[y]ou may submit written comments, documents, records and other information relating to your

claim” (ibid.) (emphasis added). The plan policy was less demanding than the April 28 letter,

which requires that “[y]our appeal letter should be signed, dated and clearly state your position”

(Anderson Decl. Exh. 2 at E171) (emphasis added). Because the plan policy only required

plaintiff to submit the appeal request in writing, plaintiff’s October 3 letter was enough to trigger

Hartford’s duty to give the claim file a second, independent review, even if based on only the

same record used by the first reviewer.

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It is true that the October 3 letter implied that a more formal appeal would be

forthcoming. When it did not arrive, the question is whether to conclude an appeal was intended

at all or to conclude that the claimant wished to appeal but had no new documents. In light of

the solicitude under ERISA for claimants, Hartford should have gone ahead and given a second,

independent look into the matter, treating it as an appeal without further submission subject to

the de novo review.

This matter is hereby remanded to Hartford to conduct its administrative review of

plaintiff’s claim. Because Dr. Lewis’s letter has arisen in the meantime, Hartford shall consider

it during its review process. Furthermore, due to plaintiff’s failure to point to any specific

documents in his letter to Hartford, Hartford need not produce any more material; it may proceed

to make its decision (while taking Dr. Lewis’ letter into account).

CONCLUSION

For the foregoing reasons, the motion for summary judgment is DENIED and the matter is

REMANDED to Hartford.

IT IS SO ORDERED.

Dated: February 11, 2008. WILLIAM ALSUP

UNITED STATES DISTRICT JUDGE

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