Unclear SPD Language Allows Participant to Proceed Directly to ERISA Suit
Recently, a participant sued her United Health Group health plan for denying her claim for benefits in the Northern District of California. The Plan Administrator argued that the lawsuit was premature because the participant had not completed the plan’s second level of appeal. The court found for the participant, reasoning that the SPD and denial letter did not make it explicitly clear that the second level of appeal to a committee was required. The ambiguity led the court to conclude that the plan’s second level of appeal was merely an option but not a requirement for the participant to have exhausted her administrative remedies and is allowing the suit to proceed.
This case serves as a reminder of the importance of clear communications regarding the appeals process and what is required to exhaust the plan’s administrative remedies.
Laura B. v. United Health Group Co., No. 16-1639 (N.D. Cal. Aug. 25, 2017)