Lacy v. Fulbright & Jaworski ( 2005 )

United States Court of Appeals
Fifth Circuit
F I L E D
REVISED APRIL 14, 2005
IN THE UNITED STATES COURT OF APPEALS March 30, 2005
Charles R. Fulbruge III
FOR THE FIFTH CIRCUIT Clerk
No. 04-20537
CAROLYN LACY,
Plaintiff-Appellant,
versus
FULBRIGHT & JAWORSKI, Limited
Liability Partnership Long Term
Disability Plan; UNUM LIFE INSURANCE
COMPANY OF AMERICA,
Defendants-Appellees.
--------------------
Appeal from the United States District Court
for the Southern District of Texas
(4:03-CV-387)
--------------------
Before JONES, WIENER, and CLEMENT, Circuit Judges.
PER CURIAM:
Plaintiff-Appellant Carolyn Lacy appeals the district court’s
summary judgment dismissal of her lawsuit for Long Term Disability
(“LTD”) benefits under an ERISA Plan (“the Plan”) sponsored by her
former employer, Fulbright & Jaworski, LLP (“the law firm”) and
insured by Defendant-Appellee Unum Life Insurance Company of
America (“Unum”). The district court dismissed Lacy’s suit for her
failure to exhaust administrative review rights following denial of
benefits, specifically, her untimely filing of an appeal after Unum
denied her LTD benefits. We affirm.
I. FACTS AND PROCEEDINGS
Lacy’s coverage under the Plan went into effect on February 8,
2000, one year after she started to work for the law firm. On the
effective date of her coverage, Lacy was already under a
physician’s care for congestive heart failure (“CHF”), as treatment
for which her physician had prescribed Coumadin, initially in
January 2000 and again in April that year. In December 2000, Lacy
suffered a cerebra-vascular accident (“CVA”). In June 2001 she
timely filed a claim for LTD benefits under the Plan and Unum’s
policy. After Unum reviewed her medical records, it concluded that
Lacy’s disability was caused, at least in part, by the Coumadin
that she had been taking for her pre-existing CHF. Unum wrote to
Lacy on November 26, 2001, denying LTD benefits (“the denial
notice”).
It is uncontested that Lacy did not seek administrative review
of Unum’s denial of her claim until July 9, 2003, approximately
twenty months after receiving the denial notice. When she finally
sought review, Unum rejected it as untimely, and this litigation
ensued. Unum filed a motion for summary judgment seeking dismissal
of Lacy’s action for failure to exhaust administrative remedies,
i.e., failure to file a timely appeal to the plan administrator
following Unum’s initial denial of benefits. In opposing Unum’s
summary judgment, Lacy contended that the denial notice was
2
inadequate under ERISA, excusing her failure to exhaust her
administrative remedies. Specifically, Lacy argued that the denial
notice was legally insufficient to start the running of the period
within which she could file an appeal, thereby making her 2003
appeal timely. Lacy sought to have the district court remand this
matter and direct the plan administrator to consider her appeal
from denial of benefits. The district court held that the denial
notice was sufficient as a matter of law, granted Unum’s motion for
summary judgment, and dismissed Lacy’s action. She timely filed a
notice of appeal.
II. ANALYSIS
A. Issue on Appeal
The sole issue presented is whether the denial notice, which
Lacy admittedly received, was deficient as a matter of law and thus
ineffective to trigger the running of the administrative appeal
period.
B. Standard of Review
When, as here, there are concededly no genuinely disputed
issues of material fact, the parties have filed opposing motions
for summary judgment, and one such motion has been granted on the
basis of a purely legal determination, our review is de novo.1
C. Sufficiency of Denial Notice
1
Fierros v. Tex. Dep’t of Health, 274 F.3d 187, 190 (5th
Cir. 2001).
3
A claimant who is denied benefits under an ERISA plan must
exhaust all administrative remedies afforded by the plan before
instituting litigation for recovery of benefits.2 At least
implicitly conceding that, if the denial notice was effective, her
purported appeal was untimely, Lacy insists that Unum’s denial
notice was legally inadequate. As a result, she argues, her appeal
period never began to run.
When a claim for benefits is denied, the claimant must be
furnished a written notice that sets forth particular information
in a manner that the claimant can understand. Section 1133 of
ERISA specifies:
In accordance with regulations of the Secretary, every
employee benefit plan shall ——
(1) provide adequate notice in writing to any participant
or beneficiary whose claim for benefits under the plan
has been denied, setting forth the specific reasons for
such denial, written in a manner calculated to be
understood by the participant, and
(2) afford a reasonable opportunity to any participant
whose claim for benefits has been denied for a full and
fair review by the appropriate named fiduciary of the
decision denying the claim.3
A Department of Labor (“DOL”) regulation adds a gloss on §
1133(1)’s notice requirement:
(f) Content of notice. A plan administrator or, if (c)
of this section is applicable, the insurance company,
insurance service, or other similar organization, shall
provide to every claimant who is denied a claim for
2
Hager v. NationsBank N.A., 167 F.3d 245, 247 (5th Cir.
1999).
3
29 U.S.C. § 1133.
4
benefits written notice setting forth in a manner
calculated to be understood by the claimant:
(1) The specific reason or reasons for the
denial;
(2) Specific reference to pertinent plan provisions
on which the denial is based;
(3) A description of any additional material or
information necessary for the claimant to perfect
the claim and an explanation of why such material
or information is necessary; and
(4) Appropriate information as to the steps to be
taken if the participant or beneficiary wishes to
submit his or her claim for review.4
Lacy asserts that the content of Unum’s denial notice was deficient
under § 1133 of ERISA and the DOL Reg quoted above. Our careful
study of the denial notice in the context of the statute and the
regulation satisfies us that even if the denial notice were held to
fall short of strict compliance with those requirements, it is
indisputably in substantial compliance.
We have not previously addressed whether, for purposes of
triggering an ERISA appeal period, an initial denial notice that is
in substantial compliance with the statute and the regulation will
suffice. At least seven other federal appeals courts have
addressed this question, however, and each has held that
substantial rather than strict compliance with ERISA § 1133 and DOL
Regulation § 2560.503-1(f) is all that the law requires.5 We join
4
29 C.F.R. § 2560.503-1(f). This regulation has since been
amended. As the amended version applies to claims filed on or
after January 1, 2002, the previous version applies to Lacy’s
claim. See 65 Fed. Reg. 70,246 (Nov. 21, 2000) (revising 29
C.F.R. § 2560.503-1).
5
See Burke v. Kodak Ret. Income Plan, 336 F.3d 103, 108 (2d
Cir. 2003); White v. Aetna Life Ins. Co., 210 F.3d 412, 414 (D.C.
5
those courts today and hold that the substantially compliant denial
notice sent to Lacy by Unum triggered the running of her
administrative appeal period.
D. Attorneys’ Fees
In a short paragraph at the conclusion of its brief, Unum
requests an award of attorneys’ fees. Unum did not, however, cross
appeal the district court’s refusal to grant its request for
attorneys’ fees; rather, it now asks us to do so on grounds of a
frivolous appeal. We deny this request as wholly lacking in merit.
III. CONCLUSION
Albeit arguably less than perfect, Unum’s denial notice,
whether read as a whole or parsed as to each particular provision,
is in substantial compliance with the applicable requirements of
ERISA and the DOL’s Regulation. It was thus sufficient for the
purpose of commencing the running of the period within which Lacy
could have submitted an appeal to the plan administrator. This is
particularly evident when it is recognized that the November 26,
2001 letter was an initial denial of benefits and not a denial of
Cir. 2000); Counts v. Am. Gen. Life & Accident Ins. Co., 111 F.3d
105, 108 (11th Cir. 1997); Kinkead v. SW Bell Corp. Sickness &
Accident Disability Benefit Plan, 111 F.3d 67, 69 (8th Cir.
1997); Kent v. United of Omaha Life Ins. Co., 96 F.3d 803, 807-08
(6th Cir. 1996); Sheppard & Enoch Pratt Hosp., Inc. v. Travelers
Ins. Co., 32 F.3d 120, 127 (4th Cir 1994); Halpin v. W.W.
Grainger, Inc., 962 F.2d 685, 690 (7th Cir. 1992). “Courts make
the substantial compliance determination on a case by case basis,
assessing the information provided by the insurer in the context
of the beneficiary’s claim.” White, 210 F.3d at 414 (citing
cases from the Eighth and Seventh Circuits).
6
a full and fair hearing on review.6 As the undisputed facts
confirm that Lacy’s appeal was proffered to Unum many months after
the expiration of the appeal period that we today hold was
triggered by the denial notice, she has failed to exhaust her
administrative review remedies. Accordingly, we affirm the
district court’s grant of Unum’s motion for summary judgment
dismissing Lacy’s action. We also deny Unum’s request for
attorneys’ fees on appeal.
AFFIRMED; ATTORNEYS’ FEES DENIED.
6
See Kinkead, 111 F.3d at 69 (holding that, when the appeal
process is adequately described, the initial claim denial “need
not be extensive” to trigger the appeal process, “provided that
it explains the basis for the adverse initial decision
sufficiently to permit the claimant to prepare an informed
request for further review”).
7