Employee Benefits & Executive Compensation Blog

The View from Proskauer on Developments in the World of Employee Benefits, Executive Compensation & ERISA Litigation

Category Archives: Benefit Claim Procedures

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ERISA Participant’s Supplemental Submission Doesn’t Restart Exhaustion Clock

A federal district court in New Jersey held that supplemental documentation submitted by a participant in connection with the claims review process did not restart the clock for a claims administrator to decide the participant’s appeal.  Plaintiff Tracee Lewis-Burroughs timely appealed Prudential Insurance Company of America’s decision to stop paying her long-term disability benefits.… Continue Reading

Ninth Circuit Rules Beneficiary Designation Forms Are Not Documents and Instruments Governing the Plan

In Becker v. Mays-Williams, 13-35069-cv, 2015 WL 348872 (9th Cir. Jan 28, 2015), the Ninth Circuit – in a matter of first impression – concluded that beneficiary designation forms were not “documents and instruments governing” an ERISA plan, as described in Section 404(a)(1)(d) of ERISA.  A participant called the plan office and telephonically re-designated his … Continue Reading

Eighth Circuit: “Satisfactory to Us” Plan Language Sufficient to Entitle Plan Fiduciary to Deferential Review

The Eighth Circuit recently held that language in Prudential’s disability policy requiring proof of disability that is “satisfactory to Prudential” was sufficient to grant the plan discretionary authority and entitled the plan to a deferential judicial review. Prezioso v. Prudential Ins. Co. of Am., No. 13-1641, 2014 WL 1356862 (8th Cir. April 4, 2014) (unpublished). … Continue Reading

District Court Concludes Statute of Limitations Defense Must Be Asserted During Administrative Claims Process

Plan administrators sometimes are confronted with claims that appear untimely, but nevertheless focus solely on the substantive issue raised by the claim. A recent ruling from a federal district court in New Jersey suggests that the failure to address procedural issues may result in a finding that such defenses have been waived. In Becknell v. … Continue Reading

Defendants See Success With Limitations Defenses Post Heimeshoff

Defendants have recently received three favorable decisions involving contractual and statutory limitations defenses. In each case, a federal court held that claims for benefits under ERISA plans were time-barred. Costa v. Astoria Fed. Sav. and Loan Ass’n, 2014 U.S. Dist. LEXIS 14292 (E.D.N.Y. Feb. 4, 2014); Paulus v. Isola USA Corp. Ret. Plan, 2014 U.S. … Continue Reading

Sixth Circuit Rejects Claim for Reinstatement of Erroneous Benefit Payments to Ineligible Retiree

In Adams v. General Motors Company (Case No. 12-2084), the Sixth Circuit rejected an ineligible retiree’s claim for reinstatement of erroneous benefit payments under her former employer’s pension plan. The retiree received benefit payments for twenty-one months before the plan administrator realized that she was ineligible for benefits under the plan and ceased further benefit … Continue Reading

“Plan Administrator” vs “Claims Administrator” – Who is the Proper Defendant in ERISA Claim for Benefits?

The issue of who may be a proper defendant in an ERISA claim for benefits has not received consistent treatment in the courts. On the one hand, a federal district court in Minnesota recently concluded that a third party administrator was a proper defendant in a lawsuit seeking benefits on the grounds that Section 502(a)(1)(B), … Continue Reading

Claims Administrator Not Liable Under ERISA For Alleged Failure to Follow ACA’s Enhanced Benefit Claim Procedures

A federal court in New York appears to have issued the first published decision addressing alleged violations of the enhanced benefit claim procedures arising out of the Affordable Care Act (ACA). The new procedures contain various participant-friendly provisions, such as the right to external review, that alter ERISA’s existing benefit claim procedures for non-grandfathered welfare … Continue Reading

View From Proskauer: Clear the Confusion to Ensure ERISA Plan Exhaustion

Background The U.S. Court of Appeals for the Second Circuit recently joined the U.S. Courts of Appeals for the Seventh and Eleventh Circuits in concluding that Employee Retirement Income Security Act plan participants are not required to exhaust their administrative remedies when “they reasonably interpret the plan terms not to require exhaustion.” Applying this principle, … Continue Reading

Second Circuit: Deferential Standard Applies Without Notice To Participants & Reimbursement Claims Are Equitable Relief

Yesterday, the Second Circuit ruled on two important issues of note for ERISA plan sponsors and plan fiduciaries. In Thurber v. Aetna Life Insurance Co., 2013 WL 950704 (2d Cir. Mar. 13, 2013), the Court ruled that participants and beneficiaries are not required to be put on notice that: the plan fiduciary has reserved discretion to … Continue Reading

Eleventh Circuit Refuses to Excuse Exhaustion

In McCay v. Drummond, 2013 WL 616923 (11th Cir. Feb. 20, 2013), the Eleventh Circuit held that deficiencies in a notice of denial of benefits did not excuse a participant’s failure to appeal within a designated 180-day time period. In so ruling, the Court reasoned that plaintiff’s allegations of defendant’s noncompliance with ERISA’s technical requirements … Continue Reading

Fifth Circuit Rules that Changed Basis for Denying Claim Violated ERISA § 503

In Rossi v. Precision Drilling Oilfield Services Corp. Employee Benefit Plan, 2013 WL 85910 (5th Cir. Jan. 8, 2013), the Fifth Circuit held that defendant violated ERISA § 503 by changing its basis for denying plaintiff medical coverage, because doing so prevented plaintiff from having a meaningful review of the denial of benefits. The court thus … Continue Reading
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