Opinion ID: 3040025
Heading Depth: 3
Heading Rank: 2

Heading: Time to File Administrative Review

Text: Second, Appellants assert that Hahnemann failed to timely file its request for administrative review under the terms of the Allshore Plan. Hahnemann filed its request for administrative review in April 2000. This review resulted in 3 Additionally, the District Court factually determined that Hahnemann’s claim would satisfy the three-year statute of limitations set forth in Section 1113(2). To the extent that this three-year period applies, it would only apply to the claim against Allshore, Inc. Furthermore, we would conclude that the District Court’s factual determination was not clearly erroneous based upon the lack of actual knowledge of the breach of fiduciary duty. See Gluck v. Unisys Corp., 960 F.2d 1168, 1177 (3d Cir. 1992). 8 NPPN concluding that the 40 % discount did not apply to Hahnemann’s claim for benefits. The Allshore Plan states that if one believed that a claim was improperly settled, the following process was available: “[w]ithin sixty (60) days of receiving notice of the claim settlement, request a review of the processed claim by written request to the Plan. The Plan will review the processed claim and inform you whether or not an error was made.” The Appellants assert that because Hahnemann did not submit its request for administrative review until April 2000 (approximately seven months after receiving the improper payment applying the 40 % discount), it did not comply with the sixty-day time period set out in the Allshore Plan. Hahnemann responds that the document which accompanied the payment applying the 40 % discount fell short of complying with ERISA’s statutory and regulatory requirements. Thus, Hahnemann asserts that the sixty-day window to apply for administrative review was never triggered. ERISA states that: In accordance with regulations of the Secretary, every employee benefit plan shall -
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
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. Furthermore, the regulations in 1999 provided that a notice of a claim denial must state: 9 (1) The specific reason for the denial; (2) Specific reference to pertinent plan provisions on which the denial is based;
material or information necessary for the claimant to perfect a claim and an explanation why such material or information is necessary; and
steps to be taken if the participant or beneficiary wishes to submit his or her claim for review. 29 C.F.R. § 2560.503-1(f)(1999).4 The Appellants do not contest that the notice to Hahnemann accompanying the September 1999 payment failed to comply with these regulations. Indeed, the accompanying document did not state any information to put Hahnemann on notice regarding how to submit a claim for administrative review. Because the letter to Hahnemann did not state the appropriate steps for administrative review, the sixty-day time bar to seek administrative review was never triggered. See, e.g., Epright v. Envtl. Res. Mgmt., Inc. Health & Welfare Plan, 81 F.3d 335, 342 (3d Cir. 1996)(citing White v. Jacobs Eng’g Group Long Term Disability Plan, 896 F.2d 344, 350 (9th Cir. 1989)).5 Accordingly, Hahnemann’s 4 The regulation has since been amended. 5 Unlike Epright, Hahnemann was not the plan participant. Rather, the patient who received the treatment at Hahnemann was the plan participant. However, the Appellants do not contest that Hahnemann is a beneficiary of the Allshore Plan. See 29 C.F.R. § 2560.503-1(f)(4)(stating that notice must state appropriate steps if beneficiary wishes to submit claim for review). Furthermore, Appellants do not contest that the plan participant assigned her claims to Hahnemann. See, e.g., Principal Mutual Life Ins. Co. v. Charter Barclay Hosp., Inc., 81 F.3d 53, 55-56 (7th Cir. 1996)(stating that if there is a valid assignment, the hospital 10 request for review seven months after actually receiving the payment applying the improper 40 % discount was timely because the sixty-day window set out in the Allshore Plan was never triggered. The fact that Hahnemann correctly guessed to submit its claim to BCI for review is of no consequence because the letter which accompanied the improper payment failed to state the proper steps that Hahnemann could take in seeking administrative review.6