Opinion ID: 622643
Heading Depth: 3
Heading Rank: 1

Heading: Full and Fair Review Standard

Text: Every benefit plan governed by ERISA must contain a two-step procedure for denying claims. See 29 U.S.C. § 1133. First, the plan participant or beneficiary shall receive “adequate notice . . . setting forth the specific reasons for [a] denial.” Id. § 1133(1); see also 29 C.F.R. § 2560.503-1(g)(1)(i)-(ii). Second, the plan 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. § 1133(2). This full and fair review must concern “the claim and the adverse benefit determination.” 29 C.F.R. § 2560.503-1(h)(1). Among other requirements, the full and fair review must give the claimant “the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits.” Id. § 2560.503-1(h)(2)(ii). Under this framework, a claimant does not receive a full and fair review if the administrative appeal decision justifies the denial of benefits based on newly asserted grounds. Such grounds do not concern “the decision denying the claim,” 29 U.S.C. § 1133(2), do not address “the adverse benefit determination” in the first instance, 29 C.F.R. § 2560.503-1(h)(1), and deny a claimant the opportunity to submit materials that rebut the original adverse determination and support a claim for benefits, id. § 2560.503- -10- 1(h)(2)(ii). Denying a claim at the administrative appeal stage based on grounds not asserted in the initial claim denial is thus a violation of ERISA’s procedural requirements. See Robinson v. Aetna Life Ins. Co., 443 F.3d 389, 393-94 (5th Cir. 2006); Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 871-72 (9th Cir. 2008). Nonetheless, courts can require a showing of prejudice due to an ERISA violation as a prerequisite to ordering a remand. See, e.g., DiGregorio, 423 F.3d at 16 (“Claimant must demonstrate how a plan’s flawed procedure prejudiced review of her claim.”); Schleibaum v. Kmart Corp., 153 F.3d 496, 503 (7th Cir. 1998) (concluding that remand to the administrator based on a § 1133 violation “was not required . . . because a remand would be futile”).