ERISA plan administrators are constantly pressured by claimants to render decisions quickly…. This is especially true with short term disability claims.
You already know that ERISA regulations require that disability claim benefit decisions be made “within a reasonable time but not later than 45 days after receipt of the claim.” 29 CFR § 2560.503-1. This period may be extended “for up to 30 days” twice, under certain circumstances.
So, what does “within a reasonable time but not later than 45 days” really mean?
Can one get into trouble by deciding a claim too quickly? Yes! “Slowing down is sometimes the best way to speed up.”
Here’s the case of Speca v. Aetna Life Ins. Co., 2019 WL 3754210 (D. Nev. August 8, 2019)(Initial claim denial made within 14 days of claim submission: “Defendant should have—at a minimum—waited a few more days to gather medical records before denying Plaintiff’s initial claim.”)
FACTS: On November 7, 2015 Speca submitted a claim for ERISA-governed short term disability benefits. The Plan terms stated that decisions on claims for disability would be made “as soon as possible but not later than 45 calendar days after the claim is made.” The Plan also had the right to “extend the 45 day window twice, by 30 days each time,” if the claimant was notified “within the first 45 days of its intent to extend.”
-November 9, 2015: Aetna began attempting to obtain records from physicians. There was some difficulty reaching Speca to obtain information to retrieve records. Aetna informed Speca that it intended to make its decision on his claim within 14 days from the date he first submitted the claim, and urged him to call Aetna to provide further information.
-November 20, 2015: Aetna denied the claim in part because Aetna had not received records from Speca’s treating physicians. Speca appealed, and submitted additional records. And, Aetna retained a doctor to perform an independent record review of the records provided. Aetna then denied the appeal, and Speca brought suit.
ISSUE: Whether Speca was afforded a “full and fair” review of his claim?
DISTRICT COURT HELD: NO.
- “[N]othing in the Policy required Defendant to decide within 14 days….Therefore, Defendant’s argument that it had to deny Plaintiff’s claim at the conclusion of a 14-day investigation even while it was waiting on medical records is unpersuasive.” Op. at 6-7.
- “While Defendant left Plaintiff several messages stating it would decide his claim by November 20, the administrative record reflects that he did not understand those messages, or may have not received them.” Op. at 7.
- “Defendant should have—at a minimum—waited a few more days to gather medical records before denying Plaintiff’s initial claim.” Op. at 7.
- “[E]ven if Defendant ultimately made the right decision on the merits during Plaintiff’s appeal, it never reached the merits of the claim until that appeal….Plaintiff essentially received his initial claim review during his appeal with Defendant [and this denied Plaintiff] a full and fair review….” Op. at 7-8.