Hartford Life & Accident Insurance Co. convinced the First Circuit that neither state law nor ERISA excused a doctor’s late-filed administrative appeal.
New Hampshire’s “notice-prejudice” rule—which makes it harder for insurers to deny late-filed claims—doesn’t apply to benefit claims under the Employee Retirement Income Security Act, the U.S. Court of Appeals for the First Circuit held Feb. 20. The court followed decisions of the Seventh and Ninth circuits, adding that “no federal court has applied any state’s common law notice-prejudice rule” to a late-filed appeal made to an ERISA plan.
The doctor also cited ERISA’s substantial compliance doctrine—which excuses an insurer’s failure to strictly follow the statute’s notice requirements if certain conditions are met—as a justification for her two-month delay in challenging Hartford’s benefit denial. The First Circuit again followed the Seventh Circuit to hold that this doctrine can excuse missteps by insurers, but not plan beneficiaries.
The substantial compliance doctrine is aimed at ensuring “fair and prompt” enforcement of ERISA rights, the court said. This goal would be frustrated by applying the doctrine to excuse late-filed appeals, the court said.
The First Circuit’s opinion didn’t consider a question raised in the doctor’s initial lawsuit: whether the Americans with Disabilities Act bars disability plans from offering different benefit levels for disabilities caused by mental and physical ailments. According to the doctor, the First Circuit in 2015 left open the possibility that the ADA could be violated by different benefit levels. A majority of circuits—Second, Third, Fourth, Sixth, Seventh, Ninth, and Tenth circuits—have held otherwise.
The district court followed the majority position and rejected the doctor’s argument. She didn’t challenge this ruling on appeal.
Judge Sandra L. Lynch wrote the decision. Judges O. Rogeriee Thompson and David J. Barron joined.
Jonathan M. Feigenbaum represented the doctor. Ogletree Deakins Nash Smoak & Stewart PC represented Hartford.
The case is Fortier v. Hartford Life & Accident Ins. Co., 2019 BL 55547, 1st Cir., No. 18-1752, 2/20/19.
To read more from Benefits & Executive Compensation News pleaseOR Request Trial