Johnson v. Health Care Service Corporation, 5:16-cv-01271

Ashley Johnson (formerly Gammon) was covered under an employer-established BlueChoice ERISA health plan; Edwin Center was plan administrator and HCSC (Blue Cross/Blue Shield of Oklahoma) was insurer/claims administrator.
Johnson received medical treatment after a January 2012 auto accident; many providers had her insurance information but did not submit claims to HCSC within the plan’s required filing period.
The plan required a "Properly Filed Claim" to be furnished to the Plan within 90 days after the end of the calendar year in which services were rendered (i.e., by March 31, 2013 for 2012 services), and imposed a three-year limitations period to sue for benefits.
HCSC paid several early claims and sent EOBs, but later received additional provider claims in August–September 2013 and denied them as untimely under the plan; Johnson did not exhaust the plan’s internal appeals before suing.
Johnson’s counsel wrote HCSC in February 2014 asserting providers failed to file timely claims and requesting payment; HCSC asserted its subrogation/reimbursement rights and sought information; communications thereafter were minimal and claims remained denied.
The district court reviewed the administrative record under the abuse-of-discretion standard (plan conferred discretion to administrator) while noting the insurer/administrator conflict; it concluded HCSC did not abuse its discretion in denying benefits as untimely.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether HCSC abused its discretion in denying benefits as untimely under the ERISA plan	Johnson contends she provided insurance information to providers and thus gave timely notice; she also claims she was not given a benefit booklet and was unaware of deadlines	HCSC argues the plan required a "Properly Filed Claim" furnished to the Plan by March 31, 2013; providers failed to file timely claims and plaintiff did not meet plan or suit deadlines	Court held HCSC did not abuse its discretion; denials for untimeliness upheld
Whether employer/administrator (Edwin Center) or insurer (HCSC) was responsible for furnishing SPD and whether lack of booklet excuses untimely filing	Johnson argues she did not receive the summary plan description and so was unaware of deadlines	HCSC and the plan point out ERISA requires the plan administrator (Edwin Center) to provide the SPD and the plan itself states the employer is responsible; lack of SPD from insurer is not a defense to plan terms	Court held plaintiff’s argument failed; employer, not insurer, had SPD duty and plaintiff gave no other reason to excuse untimely claims

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (establishes de novo review unless plan gives administrator discretionary authority; if so, review for abuse of discretion)
Weber v. GE Group Life Assur. Co., 541 F.3d 1002 (court considers only administrator’s rationale in administrative record and construes plan if unambiguous)
Holcomb v. Unum Life Ins. Co. of Am., 578 F.3d 1187 (conflict-of-interest where insurer is decisionmaker is a factor weighted in abuse-of-discretion review)
Flinders v. Workforce Stabilization Plan of Phillips Petroleum Co., 491 F.3d 1180 (same principle limiting review to administrator’s articulated rationale)
Salisbury v. Hartford Life and Acc. Co., 583 F.3d 1245 (reasonable ERISA-plan limitations periods are enforceable)
Salzer v. SSM Health Care of Oklahoma Inc., 762 F.3d 1130 (ERISA preempts state-law benefits-related claims)
Holmes v. Colorado Coal. for Homeless Long Term Disability Plan, 762 F.3d 1195 (plan administrator, not insurer, bears SPD delivery obligation under ERISA)