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Green v. The Prudential Insurance Company of America

United States District Court, M.D. Louisiana

April 24, 2018

MARC C. GREEN
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA

          RULING

          JOHN W. DEGRAVELLES, UNITED STATES DISTRICT COURT JUDGE

         Before the Court is a Motion to Stay Pending Exhaustion of Administrative Remedies filed by the Defendant, The Prudential Insurance Company of America.[1] Plaintiff. Marc C. Green, has filed an Opposition to which the Defendant has filed a Reply[2] For die following reasons, the Motion shall be granted.

         I. FACTUAL AND PROCEDURAL BACKGROUND

         Marc C. Green ("Plaintiff" or "Green") has asserted a claim pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA") against The Prudential Insurance Company of America ("Defendant" or "Prudential"), arising out of Prudential's decision to terminate Green's claim for long-term disability benefits ("LTD benefits").[3]

         Green alleges that in December of 2009, while insured under his former employer's employee benefits plan that was issued by Prudential, he "became, is now and will remain in a continuous state of disability and/or reduced ability to perform his own occupation or secure any gainful occupation due to a combination of medical conditions affecting [his] left ring finger."[4] Green applied for LTD benefits under the plan's disability insurance policy.[5] Prudential, as the Claims Administrator, is responsible for determining eligibility for LTD benefits and insuring LTD benefits under the plan.[6]

         Initially, Prudential granted Plaintiffs claim and awarded LTD benefits effective June 16, 2010.[7] However, in a letter dated April 21, 2017, Prudential informed Green that it had conducted its own review of his claim for LTD benefits, and "determined that the medical information received did not support impairment that would prevent [him] from performing material and substantial duties of any gainful occupation."[8] As a result, Prudential terminated Green's claim for LTD benefits effective April 22, 2017.[9] In this same letter, Prudential informed Green that he had the right to appeal the decision, and delineated the procedure for doing so.[10]

         Subsequently, Green submitted a letter dated May 9, 2017 to Prudential, which was captioned as an "ADMINISTRATIVE APPEAL" and provided as follows:

Please consider this as [Green's] written request for review/administrative appeal of the denial of benefits communicated by letter dated April 21, 2017 on the grounds that the list of 'gainful occupations' identified in that letter is insufficient as grounds for terminating benefits.[11]

         The letter also included a request for copies of the entire claims file, including "[a]ll governing plan documents;" "[a]ll documents that are 'relevant' to the claim in question;" "[t]he entire claim file including ... any applications, correspondence, handwritten notes, any and all surveillance, e- mails, activity logs, medical reports, vocational reports, evaluation notes and any and all commentary by any employee or person contracted by Liberty Mutual [sic] or claimant's employer regarding the claim;" "[a]ll applicable claims manuals:" and die "[c]urriculum vitae for any physician who played any part in the evaluation of this claim."[12]

         Prudential responded to Green's letter on May 16, 2017, and provided him with the requested information.[13] Prudential's letter also included the following: "Please ensure your complete appeal submission is received by Prudential within 180 days receipt of the most recent decision letter dated April 21, 2017, Thus Mr. Green's complete appeal is due no later than November 7, 2017."[14] Without submitting any additional information for Prudential to review, Green filed the instant lawsuit on October 10, 2017.[15]

         Prudential now moves die Court to stay and remand this matter to its claims administrator, because it contends that Green failed to exhaust his administrative remedies as required by ERISA. In response, Green argues that because Prudential failed to timely issue a determination on his May 9, 2017 administrative appeal, his administrative remedies were exhausted pursuant to statutory regulation, 29 C.F.R. § 2560.503-1 (1)(1). Therefore, Green contends that he had the right to file the instant lawsuit.

         II. LEGAL STANDARD

         An individual claiming benefits owed under an ERISA plan "must first exhaust available administrative remedies under the plan before bringing suit to recover.[16] "This requirement minimizes the number of frivolous ERISA lawsuits, promotes consistent administration of claims, provides a nonadversarial dispute resolution process, and decreases the time and costs of claims settlement."[17] However, when the plan administrator fails to follow claims procedures consistent with the regulatory requirements, "a claimant shall be deemed to have exhausted the administrative remedies available under the plan."[18] And yet, "the administrative remedies available under a plan with respect to claims for disability benefits will not be deemed exhausted based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the claimant so long as the plan demonstrates that the violation was for good cause or due to matters beyond the control of the plan and that the violation occurred in the context of an ongoing, good faith exchange of information between the plan and the claimant."[19]

         III. ...


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