Opinion ID: 1767685
Heading Depth: 2
Heading Rank: 4

Heading: Federal claims-handling procedures

Text: Finally, Selmon asserts that MetLife did not comply with federal ERISA claims-handling regulations because it failed to provide him adequate notice that his claim was being terminated and failed to provide a timely review. Under 29 C.F.R. § 2560.503-1(g)(1), an ERISA plan administrator must provide a claimant written notice of a benefit determination, which includes, among other things, the specific reason or reasons for the adverse determination, reference to the specific plan provisions on which the determination is based, and 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. 29 C.F.R. § 2560.503-1(g)(1)(i)-(iii) (2007). Here, MetLife initially terminated his benefits based upon his failure to comply with the plan provisions, which required him to remain under the regular care of a physician. In April 2001, a MetLife representative phoned Selmon and asked him for medical records from March 2000 until April 2001, and the MetLife representative informed him that in order to remain eligible for benefits under the plan, he must see a physician regularly. Finally, in June 2001, when Selmon still had not supplied MetLife with medical records for the past year, MetLife sent him a letter terminating his benefits, which contained a description of the reason his benefits were terminated, the plan provision he allegedly violated, and what material was missing from his file, namely updated medical records. Accordingly, we conclude that MetLife complied with the notice requirements set forth in 29 C.F.R. § 2560.503-1(g)(1). Pursuant to 29 C.F.R. § 2560.503-1(h)(4)(i), a plan administrator must notify a claimant of a benefits determination on review within sixty days after the receipt of the claimant's request for review, unless the plan administrator determines that there are special circumstances that require an extension of time for processing the claim, but in no event shall an extension exceed sixty days after the initial sixty day period. 29 C.F.R. § 2560.503-1(h)(4)(i) (2007). In April 2003, Selmon requested an opportunity to supplement the administrative record with updated medical records. MetLife granted Selmon permission to supplement the record but requested that all information be submitted by May 19, 2003, when MetLife would begin its review. Then, on June 17, 2003, MetLife contacted Selmon's attorney, indicating that it needed an extension in the time for review in order to have an independent physician review Selmon's file. After June 17, Selmon continued to send MetLife updated medical information, and on August 29, 2003, MetLife sent Selmon another letter indicating that an extension was needed to review the additional information Selmon had provided. Then, on September 19, 2003, MetLife sent Selmon a letter stating its decision that the termination of his benefits would be upheld. We conclude that MetLife complied with the timing requirements for a benefits-determination review. Selmon knew that MetLife would begin reviewing his claim on May 19, 2003. The initial sixty-day review period ended July 19, 2003, and MetLife's extension period ended on September 19, 2003, the date it sent Selmon a letter confirming its decision on review. For all of the above-stated reasons, we affirm.