Cole v. Central States Southeast & Southwest Areas Health & Welfare Fund
Opinion of the Court
Pro se plaintiff-appellant Richard A. Cole, M.D., challenges the district court’s grant of summary judgment to defendant Central States, Southeast and Southwest Areas Health and Welfare Fund (“Central States”) and denial of his claim under Section 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132(a)(1)(B), for nonpayment of benefits for medical services rendered to a Plan beneficiary. We affirm essentially for the reasons set forth in the district court’s August 28, 2003, Memorandum and Order. We add only that Cole has not demonstrated that Central States’ denial of his claim failed to comply with ERISA’s statutory and regulatory notice requirements, 29 U.S.C. § 1133; 29 C.F.R. § 2560.503-1(0.
Cole argues that Central States’ “mantra” of “routine physical examination” was too conclusory to provide adequate notice of the reason for the denial to allow him to prepare for administrative review, and he maintains that Central States should have given him a line-by-line explanation for its denial of each charge. However, this level of detail is not required by the statute or regulations. Rather, the requirements are satisfied so long as the claimant is “supplied with a statement of reasons that,
Cole’s argument that Central States violated the notice requirements because it did not inform him of the specific documentation or information needed to “rehabilitate” his claim is unavailing because Central States never suggested that more information was needed to perfect the claim and allow for adequate review. See Terry v. Bayer Corp., 145 F.3d 28, 39 (1st Cir. 1998); Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 236 (4th Cir. 1997); Brehmer v. Inland Steel Indus. Pension Plan, 114 F.3d 656, 661-62 (7th Cir. 1997). Central States did not reject Cole’s claim as defective; it only found that his arguments did not refute the opinion of its medical consultant. It was also obvious from the alternative disposition of the February 27, 1991, bill as untimely submitted that, in order to successfully appeal that determination, Cole would have to prove that he submitted it within the limitations period. His contention that he did not attempt to do so because the notices failed to advise exactly what he needed to produce to prevail on appeal is not an adequate excuse. The record demonstrates that Cole received a full and fair administrative review.
The judgment of the district court is affirmed. See 1st Cir. Loe. R. 27(c).
Reference
- Full Case Name
- Richard A. COLE, M.D. v. CENTRAL STATES SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND
- Cited By
- 2 cases
- Status
- Published