Source: http://ma.findacase.com/research/wfrmDocViewer.aspx/xq/fac.20160503_0000589.DMA.htm/qx
Timestamp: 2018-02-23 20:18:41
Document Index: 212920023

Matched Legal Cases: ['§ 2560', '§ 2', '§ 1133', '§ 1133', '§ 2560', '§ 2560', '§ 2560', '§ 2560', '§ 2560', '§ 2560', '§ 2506', '§ 2560']

Plaintiff Diane McCarron ("McCarron") seeks reimbursement of out of network health benefits from a group health insurance plan ("the Plan") regulated by the Employee Retirement Income Security Act of 1974 ("ERISA"). Defendants Deloitte LLP ("Deloitte") and United Healthcare & Affiliates ("United") move for summary judgment. The motion is DENIED.
Defendants assert that this action is time-barred by the Plan's limitation of action provisions. When a claim is denied, ERISA's implementing regulations require that the claimant be notified of the denial and be provided "[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 [ERISA] following an adverse benefit determination on review." 29 C.F.R. Â§ 2560.503-1(g)(1)(iv). If the plan administrator fails to notify a claimant of such a limitation of action provision in the adverse benefit determination letter, the plan's limitation of action provision does not apply. Santana-Diaz v. Met. Life Ins. Co., ___ F.3d ___, 2016 WL 963830, at *8 (1st Cir. Mar. 14, 2016). Rather, the forum state's most analogous statute of limitations applies. Id.
Here, none of United's letters in the summary judgment record make any mention of the plan's limitation of action provision. Therefore, Massachusetts' six-year statute of limitations for contract actions applies to McCarron's claims.[1] Mass. Gen. Laws ch. 260, Â§ 2. McCarron initiated this lawsuit in state court on January 12, 2015. No breach purportedly occurred until after McCarron sent her first claim to United on January 19, 2009. Accordingly, this action is timely.
Defendants also contend that they are entitled to summary judgment because McCarron failed to exhaust her administrative appeal remedies. Ordinarily, "[a] plaintiff who wishes to raise an ERISA claim in federal court must first exhaust all administrative remedies that the fiduciary provides." Medina v. Met. Life Ins. Co., 588 F.3d 41, 47 (1st Cir. 2009). 29 U.S.C. Â§ 1133 requires that such administrative appeal remedies be made available to the claimant, specifying that the plan must "provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a matter calculated to be understood by the participant" and must "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. Â§ 1133(1), (2). 29 C.F.R. Â§ 2560.503-1, in turn, sets forth specific requirements for such claims procedure and review and Â§ 2560.503-1(1) provides that "[i]n the case of the failure of a plan to establish or follow claims procedures consistent with the requirement of [29 C.F.R. Â§ 2560.503-1], a claimant shall be deemed to have exhausted the administrative remedies available under the plan and shall be entitled to pursue any available remedies under section 502(a) of [ERISA] on the basis that the plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim." 29 C.F.R. Â§ 2560.503-1(1). The claims procedures for a plan will be "deemed to be reasonable" only if they comply with certain specified requirements, including those governing the timing and content of benefit determination notices. Id . Â§ 2560.503-1(b)(1), (f), (g). Section 256.503-1(1) is "unequivocal that any failure to adhere to proper claims procedure is sufficient to deem administrative remedies exhausted." Linder v. BYK-Chemie USA, Inc., 313 F.Supp.2d 88, 94 (D. Conn. 2004).
29 C.F.R. Â§ 2560.503-1(g)(1) specifies that any notice of an "adverse benefit determination"- i.e., a claim denial-be provided to "a claimant" in writing or electronically and contain "in a manner calculated to be understood by the claimant" information including a description of the plan's review procedures and the time limits applicable to such procedures, and a statement of the claimant's right to bring a civil action under section 502(a) of ERISA following an adverse benefit determination. Here, neither of the two letters United sent to McCarron include this information. See Decl. Jennifer Kinberger Supp. Defs.' Mot. Summ. J. ["Kinberger Decl."], Ex. D 59 (Oct. 5, 2009 Letter to McCarron), 55-56 (Jan. 28, 2011 Letter to McCarron) [#30-4].
The summary judgment record shows that United did send several letters to McCarron's provider, Dr. Harrington, purporting to deny his claims. See id. at 58 (Sept. 17, 2009 Letter to Harrington I), 50 (Sept. 17, 2009 Letter to Harrington II), 53 (Mar. 16, 2011 Letter to Harrington). United also sent copies of these letters to McCarron's husband, Robert Carleo. See id. at 51 (Sept. 17, 2009 Letter to Carleo I), 61 (Sept. 17, 2009 Letter to Carleo II), 52 (Mar. 16, 2011 Letter to Carleo). These denial letters still do not include all of the information required by the regulations, and in any event, cannot be considered notice to McCarron of her appeal rights where United did not direct the letters to McCarron and instead included a cover page to Robert Carleo with each letter stating "[y]ou are receiving a copy of this letter to keep you informed about the status of this claim. The letter included in this envelope was sent to the physician, facility, or other health care professional. You do not need to respond or take any action at this time." Id. at 51, 52, 61 (emphasis in original). Thus, even if sending a notice to a claimant's spouse was sufficient to give notice of an adverse benefit determination "in a manner calculated to be understood by the claimant" as required by 29 C.F.R. Â§ 2506.503-1(g)(1)-and United has cited no authority to suggest that it is-the notice was not sufficient here because the letter sent to McCarron's spouse stated that no action needed to be taken at the time.
C. McCarron's Failure to Provide Timely Proof in Support of Her Claim
Defendants contend that McCarron's failure to provide United with required information within eighteen months of the dates of service bars recovery here. The court rejects this ground where it is undisputed that McCarron initiated each of three claims within eighteen months of the dates of service and where the record demonstrates that Defendants failed to timely request additional information as to the first two claims and failed to give McCarron any deadline for submission of additional information as to the third claim.
In January 2009, McCarron submitted her first claim, requesting reimbursement for thirteen dates of service between August 26, 2008, and December 2, 2008. Kinberger Decl. Ex. D 3-9 [#30-4]. This claim was thus initiated within eighteen months of the date of service. 29 C.F.R. Â§ 2560.503-1(f)(iii)(B) requires that where additional information is needed, the plan administrator must allow or deny the claim within thirty days or must give "notice of extension" within this same thirty days after receipt of the claim, and must "specifically describe the required information" necessary to ...