United States District Court, D. Massachusetts
MEMORANDUM & ORDER
TALWANI, District Judge.
Diane McCarron ("McCarron") seeks reimbursement of
out of network health benefits from a group health insurance
plan ("the Plan") regulated by the Employee
Retirement Income Security Act of 1974 ("ERISA").
Defendants Deloitte LLP ("Deloitte") and United
Healthcare & Affiliates ("United") move for summary
judgment. The motion is DENIED.
Limitation of Action
assert that this action is time-barred by the Plan's
limitation of action provisions. When a claim is denied,
ERISA's implementing regulations require that the
claimant be notified of the denial and be provided "[a]
description of the plan's review procedures and the time
limits applicable to such procedures, including a statement
of the claimant's right to bring a civil action under
[ERISA] following an adverse benefit determination on
review." 29 C.F.R. Â§ 2560.503-1(g)(1)(iv). If the plan
administrator fails to notify a claimant of such a limitation
of action provision in the adverse benefit determination
letter, the plan's limitation of action provision does
not apply. Santana-Diaz v. Met. Life Ins. Co., ___ F.3d ___,
2016 WL 963830, at *8 (1st Cir. Mar. 14, 2016). Rather, the
forum state's most analogous statute of limitations
none of United's letters in the summary judgment record
make any mention of the plan's limitation of action
provision. Therefore, Massachusetts' six-year statute of
limitations for contract actions applies to McCarron's
claims. Mass. Gen. Laws ch. 260, Â§ 2. McCarron
initiated this lawsuit in state court on January 12, 2015. No
breach purportedly occurred until after McCarron sent her
first claim to United on January 19, 2009. Accordingly, this
action is timely.
Exhaustion of Administrative Remedies
also contend that they are entitled to summary judgment
because McCarron failed to exhaust her administrative appeal
remedies. Ordinarily, "[a] plaintiff who wishes to raise
an ERISA claim in federal court must first exhaust all
administrative remedies that the fiduciary provides."
Medina v. Met. Life Ins. Co., 588 F.3d 41, 47 (1st
Cir. 2009). 29 U.S.C. Â§ 1133 requires that such
administrative appeal remedies be made available to the
claimant, specifying that the plan must "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 matter calculated to be understood by the
participant" and 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. Â§ 1133(1), (2). 29 C.F.R. Â§ 2560.503-1, in turn, sets
forth specific requirements for such claims procedure and
review and Â§ 2560.503-1(1) provides that "[i]n the case
of the failure of a plan to establish or follow claims
procedures consistent with the requirement of [29 C.F.R. Â§
2560.503-1], a claimant shall be deemed to have exhausted the
administrative remedies available under the plan and shall be
entitled to pursue any available remedies under section
502(a) of [ERISA] on the basis that the plan has failed to
provide a reasonable claims procedure that would yield a
decision on the merits of the claim." 29 C.F.R. Â§
2560.503-1(1). The claims procedures for a plan will be
"deemed to be reasonable" only if they comply with
certain specified requirements, including those governing the
timing and content of benefit determination notices.
Id . Â§ 2560.503-1(b)(1), (f), (g). Section
256.503-1(1) is "unequivocal that any failure to adhere
to proper claims procedure is sufficient to deem
administrative remedies exhausted." Linder v.
BYK-Chemie USA, Inc., 313 F.Supp.2d 88, 94 (D. Conn.
C.F.R. Â§ 2560.503-1(g)(1) specifies that any notice of an
"adverse benefit determination"- i.e., a
claim denial-be provided to "a claimant" in writing
or electronically and contain "in a manner calculated to
be understood by the claimant" information including a
description of the plan's review procedures and the time
limits applicable to such procedures, and a statement of the
claimant's right to bring a civil action under section
502(a) of ERISA following an adverse benefit determination.
Here, neither of the two letters United sent to McCarron
include this information. See Decl. Jennifer Kinberger Supp.
Defs.' Mot. Summ. J. ["Kinberger Decl."], Ex. D
59 (Oct. 5, 2009 Letter to McCarron), 55-56 (Jan. 28, 2011
Letter to McCarron) [#30-4].
summary judgment record shows that United did send several
letters to McCarron's provider, Dr. Harrington,
purporting to deny his claims. See id. at 58 (Sept.
17, 2009 Letter to Harrington I), 50 (Sept. 17, 2009 Letter
to Harrington II), 53 (Mar. 16, 2011 Letter to Harrington).
United also sent copies of these letters to McCarron's
husband, Robert Carleo. See id. at 51 (Sept. 17, 2009 Letter
to Carleo I), 61 (Sept. 17, 2009 Letter to Carleo II), 52
(Mar. 16, 2011 Letter to Carleo). These denial letters still
do not include all of the information required by the
regulations, and in any event, cannot be considered notice to
McCarron of her appeal rights where United did not direct the
letters to McCarron and instead included a cover page to
Robert Carleo with each letter stating "[y]ou are
receiving a copy of this letter to keep you informed about
the status of this claim. The letter included in this
envelope was sent to the physician, facility, or other health
care professional. You do not need to respond or take any
action at this time." Id. at 51, 52, 61
(emphasis in original). Thus, even if sending a notice to a
claimant's spouse was sufficient to give notice of an
adverse benefit determination "in a manner calculated to
be understood by the claimant" as required by 29 C.F.R.
Â§ 2506.503-1(g)(1)-and United has cited no authority to
suggest that it is-the notice was not sufficient here because
the letter sent to McCarron's spouse stated that no
action needed to be taken at the time.
summary judgment for failure to exhaust administrative
remedies is denied.
McCarron's Failure to Provide Timely Proof in Support of
contend that McCarron's failure to provide United with
required information within eighteen months of the dates of
service bars recovery here. The court rejects this ground
where it is undisputed that McCarron initiated each of three
claims within eighteen months of the dates of service and
where the record demonstrates that Defendants failed to
timely request additional information as to the first two
claims and failed to give McCarron any deadline for
submission of additional information as to the third claim.
January 2009, McCarron submitted her first claim, requesting
reimbursement for thirteen dates of service between August
26, 2008, and December 2, 2008. Kinberger Decl. Ex. D 3-9
[#30-4]. This claim was thus initiated within eighteen months
of the date of service. 29 C.F.R. Â§ 2560.503-1(f)(iii)(B)
requires that where additional information is needed, the
plan administrator must allow or deny the claim within thirty
days or must give "notice of extension" within this
same thirty days after receipt of the claim, and must
"specifically describe the required information"
necessary to ...