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Time to Appeal Runs From Date of Denial Letter Not Date of Last Payment – D.N.H.

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  • Time to Appeal Runs From Date of Denial Letter Not Date of Last Payment – D.N.H.

    Time to Appeal Runs From Date of Denial Letter Not Date of Last Payment – D.N.H.

    Attached hereto is a case out of the District of New Hampshire, Fortier v. Hartford Life and Accident Insurance Company, et. al. in this case, plaintiff seeks long-term disability benefits under an ERISA governed plan. Plaintiff was originally approved for long-term disability benefits under the open quote mental/nervous” limitation the policy. In July 2013, defendant advised plaintiff that she would reach the 24 months on September 13, 2013 and that her claim was denied beyond that point. The appeal letter gave her 180 days to appeal. Plaintiff filed her appeal on March 7, 2014 which was 219 days after the denial letter was issued. Defendant refused to consider the appeal because it asserted that it was untimely. Plaintiff filed suit and argued, in part, that the 180 day deadline should have started to run upon the date of her last payment rather than the date of the denial letter. The court disagreed.

    First, Fortier argues that her appeal was timely as a matter of law because it was filed within 180 days of September 13, 2013, the day she stopped receiving benefits under the LTD Plan. To this end, Fortier alleges that the denial of benefits in the July 17, 2013 letter was not sufficiently definite to trigger the appeals period, because the letter suggested that her benefits could be extended if she were hospitalized before September 13, 2013. The court is not persuaded by this argument.

    The July 17, 2013 letter contained both a definite explanation as to why Fortier was no longer entitled to benefits after September 13, 2013, and a definite statement that Fortier’s benefits would end on that date. Doc. no. 16-4 at 1 (“[T]he benefits will cease on 09/13/2013” (emphasis added)). Fortier does not cite, and the court cannot identify, anyauthority for the proposition that these statements somehow do not constitute an “adverse benefit determination” simply because other provisions of the ERISA plan remained in effect until the date the benefits were ultimately terminated. Indeed, Fortier’s interpretation is contrary to the plain language of the July 17, 2013 letter, the LTD Plan documents, and ERISA itself, all of which support the conclusion that the appeals period commenced once Fortier received notification that her benefits were being terminated. See doc. no. 16-3 at 15, 33 (noting that appeals must be filed within 180 days of the date the beneficiary receives a denial of coverage); doc. no. 16-4 at 3 (instructing Fortier or her representative to appeal “within one hundred eight (180) days of receipt of this letter” (emphasis added)); see also 29 C.F.R. § 2560.503—1(h)(2)(i), (h)(3)(i) (contemplating appeals period commencing upon “receipt of a notification of an adverse benefit determination” (emphasis added)). Thus, absent any contrary authority, there is no basis to conclude that the appeals period in this case commenced on any date other than the date on which Fortier received the July 17, 2013 letter.
    Another interesting argument plaintiff made was that the defendant’s denial letter was not ERISA compliant because it did not verbatim from the long-term disability plan document. The court rejected that argument as well.

    Next, Fortier argues that defendants failed to comply with ERISA because they did not copy the appeal terms from the LTD

    Plan documents into the July 17, 2013 letter. She specifically contends that the inclusion of the words “from receipt of this letter” in the July 17, 2013 letter impermissibly amended the LTD Plan. This argument, too, is unavailing.
    There is no requirement under ERISA that a notification of an adverse benefit determination quote verbatim the appeals procedure language in the governing ERISA plan document. Instead, the notification must “set forth, in a manner calculated to be understood by the claimant - the time limits applicable to [the plan's review] procedures . . . .” 29 C.F.R. § 2560.503—1(g)(1)(iv). The July 17, 2013 letter did exactly that: it explained, in plain terms, that Fortier or her representative must appeal within 180 days of the date she received notification that her claim had been denied. This language tracks closely the requirements in the LTD certification. That the July 17, 2013 letter took the additional step of making clear that the letter itself constituted the operative notification does not alter this conclusion. If anything, the inclusion of the phrase “from receipt of this letter” only enhances the likelihood that Fortier would understand that the July 17, 2013 letter constituted an adverse benefit determination and that she had 180 days from receipt thereof to appeal. Fortier’s argument to the contrary is therefore misplaced.
    Attached Files