Brown v. J.B. Hunt Transport Services, Inc.Brown v. J.B. Hunt Transport Services, Inc.
Barbara Brown (Brown) hurt her knee while working as a truck driver for J.B. Hunt Transport Services, Inc. (Hunt). Prudential Insurance Company of America (Prudential), which insured Hunt’s employee welfare benefits plan (Plan), discontinued Brown’s long-term disability (LTD) benefits and ignored her requests for information about its decision. Brown sued Hunt and Prudential under ERISA 1 for reinstatement of her LTD benefits and penalties, but the district court held she failed to exhaust her administrative remedies and dismissed her lawsuit. Because we hold Prudential failed to afford Brown a reasonable opportunity for a full and fair review of Prudential’s decision to discontinue her LTD benefits, we affirm in part, reverse in part, and remand for further proceedings.
I. BACKGROUND
A. Prudential Discontinues Brown’s LTD Benefits
Brown worked for Hunt as a truck driver and enrolled in the Plan. Hunt sponsored the Plan and served as plan administrator. Pursuant to a group insurance contract with Hunt, Prudential insured the Plan and served as claims administrator. Prudential, not Hunt, was responsible for processing claims, determining eligibility, and paying benefits under the Plan.
In August 2005, Brown stopped working for Hunt due to neck, back, and left knee pain. She made a claim for LTD benefits under the Plan. In September 2005, Prudential awarded Brown LTD benefits based upon her left knee condition. Prudential found Brown met the Plan’s definition of “disabled,” i.e., “unable to perform the material and substantial duties of [one’s] regular occupation due to ... injury.” Brown was a lifelong trucker, and her knee pain made it impossible for her to continue driving a truck.
In June 2007, Prudential discontinued Brown’s LTD benefits. The Plan’s definition of “disabled” changes after the first year of payments. The Plan states: “After 12 months of payments, you are disabled when Prudential determines that due to the same ... injury, you are unable to perform the duties of
any gainful occupation
for which you are reasonably fitted
Prudential informed Brown it had “obtain[ed] and review[ed] information” about her “medical condition,” “daily activities,” and “education, experience, and other occupations [she] would be qualified to perform.” Prudential explained that, “[b]ased on [its] clinical reviews, the medical documentation supports that [Brown had] sedentary work capacity and [was] limited to lifting up to ten pounds, stooping and bending [was] generally to be avoided, and sitting and standing [could] be alternated as needed.” Prudential indicated one of its vocational rehabilitation specialists had determined Brown was employable as a semiconductor bonder, a surveillance system monitor, a food checker, or an assembler.
Prudential notified Brown of her right to an internal administrative appeal of its decision “in writing ... within 180 days.” Prudential required any appeal to state the reasons for disagreeing with its decision and to contain supporting evidence, including: “[c]opies of therapy treatment notes,” “[a]ny additional treatment records from physicians,” “[a]ctual test results,” and “any other written comments, documents, records, or information related to [her] claim.” Prudential informed Brown of her concomitant right “to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to [her] claim.”
B. Brown Requests Information from Prudential and Hunt
In June 2007, Brown called Prudential and indicated she wanted to appeal. One of Prudential’s representatives told Brown she needed to explain in writing why she disagreed with Prudential’s decision, but Brown never did so. Instead, Brown requested a copy of the Plan from Prudential and, through her attorney, sent Hunt and Prudential a series of letters requesting a wide variety of information. Brown asked Hunt for copies of all employee welfare or pension plans in which she had enrolled and copies of all summary plan descriptions, annual reports, and amendments thereto. Brown asked Prudential for a copy of the Plan and a complete copy of the Administrative Record. Brown also requested Prudential provide her all Plan documents, internal guidelines, and administrative precedents upon which Prudential had relied when deciding to discontinue her LTD benefits, as well as the names and addresses of all individuals who reviewed her personal health information.
At Prudential’s request, Hunt sent Brown a copy of the Plan’s summary plan description and “Wrap” document, a description of the various benefits available to Hunt employees. Hunt sent Brown copies of summary plan descriptions and benefit booklets for every plan in which she had enrolled while working for Hunt. Prudential otherwise ignored Brown’s requests. Thereafter, Brown sent Prudential another letter through her attorney, in which she demanded a response within ten days. Absent a response, Brown stated she would “assume [Prudential had] no intention of responding to [her] letter, and [would] take appropriate action.” Prudential again failed to respond to Brown’s request for information.
In January 2008, Brown’s attorney called Prudential and asked whether Brown had filed an administrative appeal. Prudential informed Brown’s attorney that Brown had not filed a written appeal. Prudential contends Brown’s deadline for filing such an appeal expired in late November 2007.
C. Relevant Prior Proceedings
In April 2008, Brown filed a two-count amended complaint against Hunt and Prudential in the district court.
3
In Count I, Brown sought an order reinstating her LTD benefits under the Plan and awarding her back benefits.
See
The district court dismissed Count I because Brown did not file a written administrative appeal of Prudential’s decision to discontinue her LTD benefits. The court held Brown did not exhaust her administrative remedies. The court reasoned there was no substantial compliance exception to ERISA’s exhaustion requirement and the futility exception did not apply.
The district court dismissed Count II as to Prudential because
II. DISCUSSION
A. Standard of Review
Brown appeals the district court’s grant of the defendants’ motions for summary judgment and the denial of her
B. Count I — Claim for Benefits
Brown contends the district court erred in dismissing Count I, her claim for LTD benefits under
1. Exhaustion of Administrative Remedies
ERISA’s exhaustion requirement finds its genesis in
In accordance with regulations of the Secretary [of Labor], every employee benefit plan shall—
(1) provide adequate notice in writing to any participant ... whose claim for benefits under the plan has been denied ..., [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.
On its face,
The exhaustion requirement is not absolute. When an ERISA-governed plan fails to comply with its antecedent duty under
2. Analysis
At first glance, Brown’s attempt to except her case from ERISA’s exhaustion requirement would appear to fail. Brown mistakenly labels her argument as a “futility” argument. The futility exception is narrow — the plan participant “ ‘must show that it is certain that [her] claim will be denied on appeal, not merely that [she] doubts that an appeal will result in a different decision.’ ”
Zhou v. Guardian Life Ins. Co. of Am.,
We must take care, however, to refrain from focusing on the facial label Brown places upon her argument while ignoring its substance.
See, e.g., Wardair Can., Inc. v. Fla. Dep’t of Revenue,
When stripped of its “futility” label, Brown’s argument is a winner. Prudential’s failure to comply with its duty under § 1133(2) to provide Brown with “a rea
One of the purposes of § 1133 is to provide claimants with sufficient information to prepare adequately for any further administrative review or for an appeal to the federal courts.
See DuMond v. Centex Corp.,
Prudential’s failures to respond deprived Brown of sufficient information to prepare adequately for further administrative review or an appeal to the federal courts. Brown did not know the identity of critical persons, including the medical and vocational experts who determined she was not disabled and who calculated her residual functional capacity.
See, e.g., Lafleur v. La. Health Serv. and Indem. Co.,
It must be emphasized the Plan required Brown to do much more than simply file a written notice of appeal to exhaust her administrative remedies. Brown was required to (1) state the reasons why she disagreed with Prudential’s decision; (2) provide medical evidence or other information to support her position, such as copies of her treatment notes and medical test results; and/or (3) submit other written comments, documents, records, or information related to her claim. In other words, unlike a court of law, Brown was required to mount a detailed challenge to Prudential’s decision at the moment she appealed. Yet Prudential deprived Brown of meaningful information necessary to do so.
The Supreme Court has stressed “[t]he relevant regulations ... establish extensive requirements to ensure full and fair review of benefit denials.”
Aetna Health Inc. v. Davila,
Under § 2560.503-l(h)(2)(iii) , a plan only provides a claimant with a full and fair review of a claim and adverse benefit determination if “the claims procedures ... [p]rovide that [the] claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits.”
Midgett,
Prudential offers no explanation for ignoring Brown’s repeated requests for information. Prudential opines Brown may have possessed most of the documents in the Administrative Record, but it remains undisputed Brown did not have access to the entire Administrative Record or identification of the medical and vocational experts, and did not know the particular bases for Prudential’s decision to discontinue her LTD benefits.
Cf. Midgett,
In sum, Prudential denied Brown a reasonable opportunity for full and fair review. Because Prudential violated § 1133(2), Brown was not required to exhaust her administrative remedies under the facts of this case.
Cf. Kinkead,
3. Remedy
The appropriate remedy for Prudential’s violation of § 1133(2) is not an award of benefits from this court. Rather, we reverse and remand this case to the district court with instructions to remand to Prudential for an out-of-time appeal.
See, e.g., Abram,
We affirm the district court’s dismissal of Count I as to Hunt, because Hunt, as plan administrator, is not the proper defendant for an award of benefits under the Plan.
See, e.g., Moore v. LaFayette Life Ins. Co.,
C. Count II — Claim for Penalties
The district court correctly dismissed Count II. Neither Prudential nor Hunt may be held liable under
1. Prudential
2. Hunt
Brown complains Hunt failed to provide her with claims manuals, and thus she is entitled to statutory penalties from Hunt under
3. Discovery
Because Hunt may not be penalized under
III. CONCLUSION
We affirm in part, reverse in part, and remand for further proceedings consistent with this opinion.
Notes
. Employee Retirement Income Security Act of 1974,
. The same attorney represented Prudential and Hunt in the district court.
. In December 2007, Brown filed a one-count complaint against Hunt in state court. Hunt removed the complaint to the federal district court, which later granted Prudential leave to intervene because it was uncontroverted Prudential, as claims administrator, was liable to pay benefits were Brown found to be disabled. The district court and the parties have proceeded on the assumption that Hunt and Prudential are both defendants in this case even though Brown did not list Prudential as a defendant in the amended complaint. As an intervenor, volunteer or assumed party, we accept Prudential as a real party in interest now included in this case.
. The parties apparently agree we also should review de novo the underlying issue of whether Brown was required to exhaust her administrative remedies.
See, e.g., Kinkead v.
Sw.
Bell Corp. Sickness & Accident Disability Benefit Plan,
. Brown also argues she substantially complied with ERISA’s exhaustion requirement. We need not reach this argument.
. We note Brown did not file a cross-motion for summary judgment in the district court. Because relevant facts are undisputed and complete, remand to the district court would only further delay the ultimate disposition of