by Steve Fields | July 21st, 2022
June 7, 2022 – U.S. Court of Appeals – 2nd Circuit – 36 F.4th 416 2022
McQuillin applied for Long Term Disability benefits due to the side effects from prostate cancer treatment. His claim was denied by the Hartford, and McQuillin appealed within the allotted timeframe. The applicable ERISA regulations require a decision on the appeal within 45 days, unless “special circumstances” require a 45-day extension. An extension may also be needed because the claimant has not provided necessary information, and then the period for making the benefit determination is tolled until the claimant provides the information.
Twelve days after McQuillin submitted his appeal, Hartford sent a letter saying it had overturned the original decision to deny the claim and that it had forwarded to the claim department to determine eligibility. By day 46, McQuillin had not heard a final decision on his appeal, so he filed suit against the Hartford.
McQuillin’s lawsuit against the Hartford was dismissed when the district court concluded that he had failed to exhaust his Long Term Disability policy’s administrative appeal remedies (a requirement under any ERISA Long Term Disability policy). However, the 2nd Circuit Court of Appeals reversed that decision, finding that the Hartford failed to provide a final decision in a timely manner as required under the applicable ERISA regulations.
The Court reasoned that the decision to overturn the original denial without making an actual determination on benefits was not a benefit determination at all, so the Hartford’s review was still subject to the 45-day requirement. Since they had not made a benefit determination on review, and they had not provided notice of utilizing an extension, McQuillin was correct in deeming his claim denied and filing suit.
The timelines and requirements under ERISA for both claimants, insurers and plan administrators are extensive. It is important to have a full understanding of these requirements. Not only does that help you avoid making a mistake which can be fatal to your Long Term Disability claim, but you can also make strategic decisions on how or when to move your claim forward. Note that not every claim may be best served by the approach taken in this case, which is why it is so important to fully understand both the regulations and the specifics of your claim. Our Long Term Disability attorneys have the comprehensive understanding of ERISA regulations to help make these decisions to put your claim in the best possible position to win.
