Opinion ID: 173034
Heading Depth: 3
Heading Rank: 2

Heading: MetLife's Review Procedure

Text: Although we ordinarily apply arbitrary-and-capricious review when an ERISA benefit plan gives discretion to the administrator or fiduciary to determine benefit claims, see Kellogg, 549 F.3d at 825, de novo review may be appropriate if the benefit-determination process did not substantially comply with ERISA regulations, see id. at 827-28. [3] Ms. Hancock contends that MetLife's determination of her claim was so procedurally defective as to warrant de novo review. In particular, she alleges (1) that MetLife's denial letters did not include information required by ERISA regulations, and (2) that MetLife did not provide a full and fair review of her appeal. We reject both contentions.
ERISA regulations require benefit-denial notifications to set forth, among other things, the specific plan provision justifying the denial as well as a description of additional information needed to perfect the claim and why the information is necessary. See 29 C.F.R. § 2560.503-1(g)(1)(ii), (iii). Ms. Hancock complains that MetLife's benefit-denial letter and its first appeal-denial letter violated this regulation by not citing the Plan provision upon which the denial was based and not explaining how she could perfect her claim. MetLife received Ms. Hancock's claim on January 20, 2005. In its March 22, 2005, denial letter MetLife explained that because both Verla Hancock's death certificate and autopsy report state that the cause of death is undetermined, accidental death has not been established and therefore Ms. Hancock is not entitled to AD & D benefits. Admin. R. at 176. The letter quoted the Plan's AD & D provision, including language that limits coverage to accidental losses. It informed Ms. Hancock of her right to appeal to MetLife, and asked her to state the reason(s) you believe the claim was improperly denied, and submit any additional comments, documents, records or other information relating to your claim that you deem appropriate to enable MetLife to give your appeal proper consideration. Id. at 176-77. On May 19, 2005, Ms. Hancock sent MetLife a letter appealing the denial of AD & D benefits. The letter argued that the autopsy report and death certificate did not preclude the possibility of accidental death and that [o]ther evidence exists... to support the conclusion that my mother's death was indeed an accident. Id. at 173. It said that she had spoken with Detective Frank Johnson of the West Valley City Police, who had investigated Verla Hancock's death, and that he had told her that her mother had apparently hit her head after slipping and falling in the bathroom. The letter further stated that Dr. Todd Grey, who had conducted the autopsy, had agreed that it was possible for Verla Hancock to have slipped and hit her head without fracturing her skull, and that decomposition could have made it hard to detect a head injury. In addition, the letter included Ms. Hancock's offer to send police photographs of the scene as additional evidence that would be helpful in further establishing the accidental nature of my mother's death. Id. MetLife denied Ms. Hancock's appeal on September 1, 2005. Neither MetLife's benefit-denial letter nor its appeal-denial letter violated § 2560.503-1(g). First, the benefit-denial letter set forth the Plan provision justifying the denial. It stated that the claim was denied for lack of evidence of accidental death, and properly cited the AD & D language that limits coverage to such losses. Ms. Hancock argues that the denial was based on an exclusion in the Plan for death caused by physical illness; but the record shows that MetLife did not rely on that provision. Second, the denial letter described what information was needed to perfect the claim and why that information was needed. It explained that to obtain AD & D benefits, Ms. Hancock must supply evidence of accidental death as required by the AD & D provision. Her own appeal letter indicates that she had understood what she had to do to contest MetLife's decision. We discern no procedural violation in MetLife's benefit-denial letter. As for MetLife's appeal-denial letter, it could not have violated § 2560.503-1(g) because that provision applies only to denials of benefits, not denials of appeals. See Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161, 1168 n. 4 (10th Cir.2007) (citing § 2560.503-1(g) to describe a plan administrator's duties in the initial denial, and citing § 2560.503-1(h) to describe its duties in the appeals process); Ellis v. Metro. Life Ins. Co., 126 F.3d 228, 237 (4th Cir.1997) (What is not required [to be included in the decision on appeal], because not relevant at this stage of the administrative review, is notice regarding how to perfect a claim or how to seek review.); cf. Midgett v. Washington Group Int'l Long Term Disability Plan, 561 F.3d 887, 894-95 (8th Cir.2009) (explaining that the adverse benefit determination is the initial benefit denial, which is to be distinguished from the determination on review. (emphases and internal quotation marks omitted)).
Ms. Hancock contends that MetLife denied her full and fair review because it (1) ignored her evidence, (2) did not respond to her forensic expert's opinion in a timely manner, and (3) failed to conduct an independent investigation of Verla Hancock's death, instead [relying] solely on the government reports. Aplt. Br. at 21. Her contentions lack merit. Every ERISA benefit plan must have a procedure giving claimants a reasonable opportunity to appeal ... and under which there will be a full and fair review of the claim and the adverse benefit determination. 29 C.F.R. § 2560.503-1(h)(1). Full and fair reviews must take[] into account all comments, documents, records, and other information submitted by the claimant. Id. § 2560.503-1(h)(2)(iv). Moreover, absent special circumstances, decisions must be rendered within 60 days of receipt of the appeal. Id. § 2560.503-1(i)(1)(i). In its first appeal-denial letter dated September 1, MetLife rejected Ms. Hancock's conversations with Detective Johnson and the medical examiner as evidence of accidental death. It said that Johnson had deferred to the medical examiner, Dr. Grey, on cause of death, and that Dr. Grey had merely speculated with Ms. Hancock and had never amended his report regarding the cause of death. Their comments, it continued, were conjecture. By letter dated February 6, 2006, Ms. Hancock appealed again. This time she submitted an investigative report prepared by MRA Forensic Sciences. MRA had conducted a slip-meter test on tiles similar to those in Verla Hancock's bathroom and found that they were slippery when wet. MRA listed factors that made a slip-and-fall accident likely, including Verla Hancock's medical problems, history of falls, and a potentially wet floor (although it provided no evidence that the tiles were wet at the time of death). The report then stated: [I]t cannot be concluded that [Verla Hancock] did not die of accidental causes. In fact, based upon the available information, there was sufficient evidence to suggest that she was prone to falling down and that she probably did fall down in the bathroom. Admin. R. at 166. Ms. Hancock's letter stated that the enclosed documents were submitted on condition that they not be used in any future litigation. MetLife received Ms. Hancock's letter on February 13, 2006. Ten days later it informed her that it would be willing to conduct a further administrative review, id. at 142, provided that she agree that her submissions be part of the administrative record that could be reviewed by a court. On March 3 Ms. Hancock agreed and asked MetLife to proceed with its review. More than three months passed with no decision from MetLife. On June 27, 2006, Ms. Hancock's attorney wrote to MetLife, noting that he had contacted MetLife over 20 times in the previous months and was always told only that the claim is in the review process, without additional explanation. Id. at 134. The letter threatened suit for breach of contract if Metlife did not pay the disputed AD & D benefits within ten days. On September 12 Ms. Hancock, still without a decision on her appeal, filed suit. MetLife denied Ms. Hancock's second appeal the next day. The denial letter stated that it only supplemented the first appeal-denial letter and did not replace it. It again cited the Plan's AD & D provision and summarized MetLife's reasons for denying the claim and the first appeal. It then stated that the MRA report d[id] not demonstrate with certainty that the decedent had an accident and that the slip-meter test said nothing about Verla Hancock's actual cause of death. Id. at 132. From this correspondence we cannot conclude that MetLife denied Ms. Hancock a full and fair review. MetLife did not ignore her evidence; it merely found it inconclusive. Both appeal-denial letters took into account the information Ms. Hancock had submitted and then reasonably explained why the information was insufficient to support the accidental-death theory. Moreover, MetLife had no duty to respond to the MRA report within a particular time. ERISA requires only that claimants be given  a reasonable opportunity to appeal. 29 C.F.R. § 2560.503-1(h)(1) (emphasis added). MetLife satisfied this requirement when it reviewed Ms. Hancock's first appeal. ERISA does not demand, and the Plan does not provide for, a second opportunity to appeal. That MetLife nevertheless considered her second appeal did not bring its response to that appeal under ERISA's regulations governing appeals. Because Ms. Hancock submitted the MRA report with her second appeal, MetLife's delay in responding to it was not a procedural defect under ERISA. Finally, Ms. Hancock contends that MetLife's failure to conduct an independent investigation denied her the required full and fair review. We disagree. Ms. Hancock's argument for such an investigation is particularly unpersuasive here, because her mother's death had been properly investigated by police detectives and a medical examinerdisinterested third parties with recognized credentials.