Exhaustion

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This week we discuss the importance of establishing good claims procedures and the benefits of following those procedures.

A plan’s claims procedures should be spelled out clearly in both the plan document and the summary plan description (where the two documents are not one in the same).  In addition to setting all of the applicable…

The First Circuit held that a plaintiff failed to timely exhaust her administrative remedies under a long-term disability plan because the plan’s 180-day time limit for submitting appeals commenced on the date the plaintiff received notice of the decision that it was going to terminate her long-term disability benefits, not the actual date her benefits…

A federal district court in California held that the ILWU-PMA Welfare Benefit Plan’s anti-assignment provision barred Brand Tarzana Surgical Institute’s claim for benefits and thus dismissed the Institute’s claim for benefits.  In so holding, the court rejected the Institute’s argument that the plan waived the right to assert the anti-assignment provision as a defense by…

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.