Opinion ID: 791819
Heading Depth: 2
Heading Rank: 2

Heading: Statutory Procedures and Requirements for Denial of Benefits

Text: 36 Ms. Schneider submits that Sentry's April 23 letter did not meet ERISA's statutory and regulatory notice requirements. We first shall review those requirements before turning to an assessment of whether the notice afforded to Ms. Schneider in the present case was appropriate. 37 ERISA mandates that specific reasons for the denial of benefits be communicated to the claimant. See Militello v. Cent. States, Se. and Sw. Areas Pension Fund, 360 F.3d 681, 688 (7th Cir.), cert. denied, ___ U.S. ___, 125 S.Ct. 106, 160 L.Ed.2d 115 (2004). The relevant section of ERISA provides: 38 In accordance with regulations of the Secretary, every employee benefit plan shall— 39 (1) 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 manner calculated to be understood by the participant, and 40 (2) 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. 41 29 U.S.C. § 1133. 42 Furthermore, federal regulations, promulgated pursuant to ERISA and in force at the time the April 23 letter was sent, set forth the following requirements for the notification of an adverse benefit determination: 43 The notification shall set forth, in a manner calculated to be understood by the claimant— 44 (i) The specific reason or reasons for the adverse determination; 45 (ii) Reference to the specific plan provisions on which the determination is based; 46 (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; 47 (iv) A description of the plan's review procedures and the time limits applicable to such procedures. . . . 29 C.F.R. § 2560.503-1(g). 2 48 In assessing the notification which a plan has provided regarding an adverse benefit determination, this court has held that substantial compliance [with the applicable regulations] is sufficient. Halpin, 962 F.2d at 690. Our determination that substantial compliance is sufficient to satisfy § 1133 was guide[d] by the purpose of the statute and regulations, all of which are designed to afford the beneficiary an explanation of the denial of benefits that is adequate to ensure meaningful review of that denial. Id. at 689-90. Thus, in asking whether substantial compliance with the regulations governing notification has been achieved, we consider: [W]as the beneficiary supplied with a statement of reasons that, under the circumstances of the case, permitted a sufficiently clear understanding of the administrator's position to permit effective review? Id. at 690.