:: Contractual Limitations Period Imposed – Equitable Tolling Argument Rejected

While it may be true that Plaintiff was never provided a copy of the Plan, despite his requests, it does not follow that Plaintiff had no way of discovering the shorter contractual limitation period. Primarily, Plaintiff could have, quite easily, requested information about the Plan from the assigning beneficiary. Plaintiff does not attempt to argue that L.N. had never received a copy of the Plan, and this Court does not believe it is inequitable to apply the Plan’s internal limitations period to someone who had the ability to learn of it. See Ortega Candelaria, 661 F.3d at 680 (citing I.V. Servs. of Am., 182 F.3d at 54).

Torpey v. Anthem Blue Cross Blue Shield, 2014 U.S. Dist. LEXIS 53342 (D.N.J. Apr. 16, 2014)

In this benefit claims case, the plaintiff was a physician who sought payment for services as an “out-of-network provider”.   Pursuant to an  “Authorization and Assignment” document he appealed the denial of claims to additional payments.

Facts

The Plaintiff  alleged that he submitted a claim to the Defendants on or about June 9, 2011 in the amount of $45,021.00 for medical services provided to the beneficiary.

On or about July 21, 2011, Defendant made an adverse benefit determination of Plaintiff’s claim by making a payment in the amount of $2,582.02, an amount that represented less than 6% of the submitted claim.

On or about September 27, 2011, Plaintiff submitted a First Level Appeal. Thereafter, Plaintiff received an appeal denial letter on or about October 19, 2011. 

Contractual Limitations Period

The plan contained a one year contractual limitations period.  Under the terms of the Plan, a beneficiary must file a lawsuit within one year of the final determination of the claim.

Thus, the Court concluded that the Plaintiff’s claims accrued, at the latest, when he received the appeals denial letter on October 19, 2011.  Therefore, the statute of limitations on Plaintiff’s ERISA claims expired as of October 19, 2012.

Equitable Tolling

The Court rejected the Plaintiff’s argument that the doctrine of equitable tolling should apply, stating:

 “[ . . . Defendant AGL substantially complied with the ERISA regulations in the complete appeal denial letter.  AGL clearly explained the basis for its adverse determination, made the beneficiary aware of her  other appeal options and her right to bring a civil action, alerted the beneficiary of when she was able to bring a civil action, and provided the beneficiary with access to her claim file or other relevant documentation upon written request. This notification was, at the very least, in substantial compliance with the governing ERISA regulation.

The Court held for the Defendant.

Note:

Substantial Compliance – The court placed the burden on the Plaintiff to learn of the plan’s internal limitations period.

The only possible short-coming is the failure to include the one-year time frame for bringing suit after a final determination of the claim. Considering, however, that the letter did inform the beneficiary of her right to bring a civil action and when she could bring a civil action and that the Plan Booklet clearly and plainly articulated the contractual limitation period (and that there is no allegation that the beneficiary did not have a copy of this Plan), it would be a stretch to find that AGL either failed to provide notice to the Plaintiff of his right to bring suit, or that AGL had materially mislead the beneficiary into missing the limitations period with its failure to include the one-year time limitation in the denial letter.

The doctrine of “substantial compliance” covered any flaws in the plan administrator’s conduct.  The Court noted that “[a]n administrator need only ‘substantially comply’ with” ERISA’s claims regulations procedures – thus the denial letter “was sufficient to discharge its obligations under the ERISA regulations.”

Plaintiff’s Burden – The Court charged the provider with knowledge imputed to his patient.  This issue merges to some extent with the duty on the plaintiff regarding diligence in asserting equitable tolling, but overall, the Court’s position seems rather harsh.

Further, Plaintiff has failed to show that he exercised reasonable diligence in attempting to uncover the relevant facts of his cause of action. While it may be true that Plaintiff was never provided a copy of the Plan, despite his requests, it does not follow that Plaintiff had no way of discovering the shorter contractual limitation period. Primarily, Plaintiff could have, quite easily, requested information about the Plan from the assigning beneficiary. Plaintiff does not attempt to argue that L.N. had never received a copy of the Plan, and this Court does not believe it is inequitable to apply the Plan’s internal limitations period to someone who had the ability to learn of it.

More on Equitable Tolling – In the context of plan information, the timing of requests for plan information can play a factor in the Court’s view:

 Furthermore, despite the appeal determination letter informing Plaintiff of his right to file a lawsuit and of his right to obtain certain documentation  pertaining to the claim denial, Plaintiff did not make a request for any relevant documentation until, at the earliest, March 14, 2012—approximately five months later.  Plaintiff did not file a second appeal until April 19, 2012, six months after receiving notice of the appeal denial and untimely by four months.

While equitable tolling does not require “maximum feasible diligence,” Ortega Candelaria, 661 F.3d at 681(quoting Holland v. Florida, 560 U.S. 631, 653, 130 S. Ct. 2549, 177 L. Ed. 2d 130 (2010)), it does require a party to show that the information could not have been found by reasonable and timely diligent inquiry. Plaintiff cannot ask this Court to equitably toll his limitations period when he has failed to show reasonable diligence in his efforts to discover the relevant facts for his underlying claims.