You already know that ERISA regulations set specific timelines for the issuance of ERISA-governed long term disability decisions. See, e.g., 29 C.F.R. 2560.503-1(i)(1)(i) (45 days for disability claims and 60 days for others). In special circumstances, the administrator can extend the time by which benefit decisions are made.
An administrator’s failure to issue benefit decisions can have consequences: in those situations a claimant shall be deemed to have exhausted administrative remedies (and can sue), and the benefit denial may be reviewed under the de novo standard even if the administrator had discretionary authority.
But what happens when the administrator issues the benefit denial just “a little late?”
Can the doctrine of “substantial compliance” excuse the late decision? NO.
Here’s the case of Fessenden v. Reliance Standard Ins. Co. and Oracle, 927 F. 3d 998 (7th Cir. June 25, 2019)(The 2002 ERISA regulation amendments preclude application of the common law substantial compliance doctrine to late issued benefit denial decisions).
FACTS: Fessenden, a software manager, sought ERISA-governed long term disability benefits due to Chronic Fatigue Syndrome. Reliance denied the claim. The denial letter outlined how he could appeal, stating that Reliance would issue its “final decision within 45 days of the date that it received a request for review… unless special circumstances existed.” If the appeal involved special circumstances, Reliance would notify him of the final decision no later than 90 days from the date that it received the request. (These deadlines are also contained in 29 C.F.R. 2560.503-1).
Before Reliance issued the final decision, but after the 90 day deadline had passed, Fessenden sued Reliance and Oracle.
ISSUE: Can the doctrine of “substantial compliance” excuse a late issued benefit denial? NO.
SEVENTH CIRCUIT HELD:
- “[W]hen a plan administrator fails to follow required procedures, such as deadlines for issuing decisions, ‘a claimant shall be deemed to have exhausted the administrative remedies available under the plan.’” Op. at 4.
- “The absence of a final decision…affects the standard of review. When a benefit plan gives the administrator discretionary authority…[but fails to render a final decision], there is no valid exercise of discretion to which the court can defer, and it decides de novo whether the insured is entitled to benefits.” Op. at 4-5.
- Reliance argued that a decision issued “a little bit late” is different from a case in which an administrator altogether fails to render a decision. And, because the decision was only a little bit late, Reliance argued the “substantial compliance” doctrine should excuse the late decision. Op. at 5.
- The “substantial compliance” doctrine, as a common law doctrine, “cannot override regulations that ERISA has authorized the Department of Labor to adopt.” Op. at 6.
- There is some question whether the “substantial compliance” doctrine exists after the 2002 amendments to the ERISA regulations. Op. at 6-9.
- Even if the substantial compliance doctrine “remains valid, it does not apply to the violation of regulatory deadlines.” Op. at 10. (emph. added).
- “[S]ubstantial compliance with a deadline requiring strict compliance is a contradiction in terms.” It runs “afoul of Section 2560.503-1(i)(1)(i), which says that ‘in no event’ can a deadline be extended further.” Op. at 11. (emph in original).
- Other circuits have been willing to apply the substantial compliance exception to missed deadlines. But those decisions “relied on precedent that predates the 2002 version of the regulations.” Op. at 14-15.