Donald Fessenden v. Reliance Standard Life Insura
Opinion
Donald Fessenden applied for long-term disability benefits through his former employer's benefits plan. After the plan administrator, Reliance Standard Life Insurance Company, denied the claim, Fessenden submitted a request for review with additional evidence supporting it. When Reliance failed to issue a decision within the timeline mandated by the regulations governing the Employee Retirement Income Security Act of 1974 (ERISA), he sought review of Reliance's decision in federal court. Eight days later, after Fessenden had already filed suit, Reliance finally issued a decision, again denying Fessenden's claim.
We must decide whether Reliance's tardiness affects the standard of review in the district court. If the decision had been timely, the court would have applied an arbitrary and capricious standard because the plan gave Reliance the discretion to administer it. When a plan administrator commits a procedural violation, however, it *1000 loses the benefit of deference and a de novo standard applies. We have recognized an exception, though, and Reliance seeks to take advantage of it: if the administrator "substantially complies" with the prescribed procedures-in other words, if the violation is relatively minor-then the court will still defer to the administrator's decision. Reliance argues that it "substantially complied" with the deadline because it was only a little bit late.
We reject Reliance's argument because we hold that the "substantial compliance" exception does not apply to blown deadlines. An administrator may be able to "substantially comply" with other procedural requirements, but a deadline is a bright line. Because Reliance violated a hard-and-fast obligation, its late decision to deny Fessenden benefits is not entitled to deference.
I.
Fessenden worked as a Software Engineer Manager for Oracle USA until January 2008, when he stopped working due to fatigue and severe, chronic migraine headaches. He applied for short-term disability benefits through Oracle's employee welfare benefits plan, a fully funded group insurance policy issued by Reliance. The request was approved, and Fessenden received benefits through May 11, 2008. Oracle terminated Fessenden shortly thereafter.
In March 2014, Fessenden submitted a claim to Reliance for long-term disability benefits dating back to his last day of work in 2008. His submission included medical records from 2006 to 2014, as well as statements from multiple doctors, all supporting his diagnosis of Chronic Fatigue Syndrome. Reliance denied his claim in an eleven-page letter stating the reasons for its decision and emphasizing the difficulties involved in reviewing a six-year-old claim. The letter told Fessenden how to request review of the decision and explained the timeline that would apply to Reliance's resolution of an appeal: Reliance would notify Fessenden in writing of its final decision within 45 days of the date that it received a request for review, unless special circumstances existed. In that event, Reliance would notify him of the final decision no later than 90 days from the date that it received the request.
See
On April 24, 2015, Fessenden submitted his request for review, complete with additional medical records and physicians' statements. But he sent it to an address different from the one included in the instructions, and Reliance did not confirm receipt of it until May 8. On June 17, Reliance notified Fessenden that it needed an additional 45 days to make its determination, and on August 27, it entered its final decision denying Fessenden's claim for long-term disability benefits. The parties disagree on when exactly Reliance's 90 days were up, but they all agree that Reliance made its final decision after the window had closed. 1
Before the final decision issued, but after the deadline had passed, Fessenden sued Reliance and Oracle under ERISA
, see
The absence of a final decision affects more than the timing of a suit-it also affects the standard of review. When a benefit plan gives the administrator discretionary authority to determine a claimant's eligibility for benefits, we typically review the denial of benefits under an arbitrary and capricious standard.
See
Here, however, Reliance did issue a final decision-it was just late in coming. Fessenden filed his suit on August 19, and Reliance denied his request for review on August 27. At that point, Fessenden sought to clarify the standard that the district court would apply in reviewing his claim. He urged the district court to ignore Reliance's August 27 decision and review his claim and supporting evidence de novo. According to Fessenden, Reliance forfeited the benefit of deference when it blew the deadline.
Reliance, on the other hand, suggested that a late decision is different from a case in which an administrator altogether fails to render a decision.
See, e.g.
,
Gilbertson v. Allied Signal
,
Inc.
,
Fessenden argued that the timing regulation precluded application of the substantial compliance exception; that Reliance had not substantially complied with the deadline in any event; and that even if Reliance had substantially complied, its decision *1002 to deny him benefits was arbitrary and capricious. The district court sided with Reliance on all three issues and entered summary judgment in its favor.
II.
Fessenden suggests that we abandon the substantial compliance exception altogether. The exception is judge-made.
See
Burns v. Orthotek, Inc. Employees' Pension Plan & Tr.,
In the case of the failure of a plan to establish or follow claims procedures consistent with the requirements of this section, 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 the Act 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.
Fessenden invokes
Halo v. Yale Health Plan
to support his interpretation.
See
While the court found the preamble instructive, the preamble did not resolve the question "whether a plan need only substantially comply with or must strictly adhere to the regulation to obtain the more deferential arbitrary and capricious standard of review."
Halo
is inconsistent with our case law because we have applied the substantial compliance doctrine even since the 2002 regulations became effective.
See, e.g.
,
Edwards
,
The 2002 regulations strike a delicate balance between the administrator's need for more time and the claimant's need for a timely decision. After all, the administrator's interests are not the only ones at stake; delaying payment of a claim imposes financial pressure on the claimant. That pressure is particularly acute for a disability claimant, who applies for disability benefits because she is unable to work and therefore unable to generate income. Given the seriousness of that burden, the new
*1004
regulations single out disability claims for quicker review than other kinds of claims.
When a claimant seeks review of an administrator's denial of benefits, the administrator must review the claim "not later than" a specified period of time-45 days for disability claims and 60 days for others.
A court that excused even more administrative delay would upset the careful balance that the regulations strike between the competing interests of administrators and claimants.
4
It would also run afoul of § 2560.503-1(i)(1)(i), which says that "
in no event"
can a deadline be extended further. That language excludes nothing-
no event
, however reasonable or harmless-from its scope. Substantial compliance with a deadline requiring strict compliance is a contradiction in terms.
Cf.
Burns
,
The regulations are not the only reason that Reliance's argument fails-applying the substantial compliance doctrine to blown deadlines is incompatible with the doctrine itself. We have said that an administrator substantially complies with ERISA's requirements if, despite the regulatory violation, it provides sufficient process and information to permit "effective review" of its denial of benefits.
See
Schneider
,
Fessenden's case highlights the point. After Reliance's initial decision denying him benefits, Fessenden had the opportunity to submit additional evidence to Reliance to support his claim on review.
See
Reliance's position that an administrator can change the standard of review with a late-breaking decision would therefore be a novel application of the substantial compliance doctrine. And permitting that novelty would undercut the benefits of exhaustion for claimants. A claimant is entitled to sue as soon as a claim is deemed exhausted because the administrator has failed to make a timely decision. But Reliance's position would leave such a claimant in an uncertain position. Should she wait a little bit longer just in case the administrator makes a decision? Or should she go ahead, attempting to frame her case in a way that is responsive to a decision that hasn't yet-but may still-come? Moreover, an administrator who has more time may get an unfair advantage: it could sandbag a claimant who sues at the point of exhaustion by issuing a decision tailored to combat her complaint.
See
Jebian v. Hewlett-Packard Co. Emp. Benefits Org. Income Prot. Plan
,
We acknowledge that some of our sister circuits have been willing to apply the substantial compliance exception to blown deadlines.
See
*1006
Gilbertson
,
We disagree.
5
As an initial matter, it is worth noting that many of the circuits currently applying the exception to missed deadlines have relied on precedent that predates the 2002 version of the regulations. The earlier version offered a much less nuanced approach to balancing the competing interests at stake, which subjected the goals of ERISA to different kinds of gamesmanship and perverse incentives.
See
Gilbertson
,
Yet whatever its merits under prior versions of the regulations, we hold that excusing late decisions is both foreclosed by the 2002 regulations and incompatible with the doctrine. It is also in significant tension with our own precedent. In
Edwards v. Briggs & Stratton Retirement Plan
, a claimant who missed a deadline argued that the substantial compliance exception should excuse her untimeliness.
[I]t seems consistent neither with the policies underlying the requirement of exhaustion of administrative remedies in ERISA cases nor with judicial economy to import into the exhaustion requirement the substantial compliance doctrine. To so hold would render it effectively impossible for plan administrators to fix and enforce administrative deadlines while involving courts in detailed, case-by-case determinations as to whether a given claimant's failure to bring a timely appeal from a denial of benefits should be excused or not.
* * *
Because the doctrine of substantial compliance does not apply to ERISA's regulatory deadlines, Fessenden's claim should have been reviewed de novo. We therefore VACATE the district court's summary judgment determination and REMAND for proceedings consistent with this opinion.
The disagreement is primarily about the operation of the regulations' tolling provisions. For our purposes, though, the only thing that matters is that the decision was untimely. Because we hold that the "substantial compliance" standard is inapplicable to ERISA's regulatory deadlines, it doesn't matter how late it was.
The regulation was amended in 2000, but the amendments apply only to claims filed on or after January 1, 2002.
See
A more recent revision to the regulations expressly overrides the substantial compliance doctrine in favor of a new standard.
See
The old version of the regulations did not attempt this same balancing act. Instead, that version gave administrators the same amount of time to review disability claims as it did all other claims, and it did not toll the time for a decision on review while the administrator waited for additional information from the claimant.
Compare
This opinion has been circulated among all judges of this court in regular service. See 7th Cir. R. 40(e). No judge favored a rehearing en banc on the question whether failure by a plan administrator to strictly comply with ERISA's regulatory deadlines results in de novo review of a benefits denial.
Reference
- Full Case Name
- Donald FESSENDEN, Plaintiff-Appellant, v. RELIANCE STANDARD LIFE INS. CO. and Oracle USA, Inc., Group Long Term Disability Plan, Defendants-Appellees.
- Cited By
- 37 cases
- Status
- Published