Greg Culbertson v. Eaton Corporation, C/A No.: 8:02-3018-24BI (D.S.C.) - decided August 22, 2003 – United States District Court for the District of South Carolina – Robert E. Hoskins

I represented Culbertson.  This opinion is not published and is not available through any dissemination service to the best of my knowledge.  However, I use this opinion frequently in my practice on a particular point.  When I handle an ERISA benefit claim during the pre-litigation claim review process, I always request a copy of the plan document from the claim administrator when I initially appeal a claim denial.  Often the claims administrator will forward the plan document.  However, it is not uncommon for a claims administrator to write back and tell me that, as claims administrator, it is under no obligation to provide the plan documents.  Claims administrators who assert that they are not obligated to provide the plan document in connection with a denied claim are operating under a misapprehension of law in my opinion.  It is clear, under ERISA, that the actual plan administrator (as opposed to the claims administrator) has an obligation to provide plan documents after receipt of a written request pursuant to ERISA 29 U.S.C.S. § 1132(c).  However, some claims administrators do not appreciate that there is, also, an obligation to provide any and all documents upon which a claim denial is based pursuant to 29 C.F.R. § 2560.503-1.  In Culbertson, the presiding Judge specifically held that a claim administrator has an obligation to provide plan documents in connection with the appeal of a denied claim.  The court wrote:

“. . . the plaintiff requested the plan documents and internal guidelines on three occasions, beginning on July 10, 2002, from its claims administrator, but he did not receive the documents until December 2002, three months after the instant lawsuit was filed.  The Code of Federal Regulations sets forth the rules and regulations for administration and enforcement of ERISA.  The regulations provide in pertinent part: 

(h)                Appeal of adverse benefit determinations.

(1)        In general.  Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination. 

(2)        Full and fair review.  Except as provided in paragraphs (h)(3) and (h)(4) of this section, the claims procedures of a plan will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures - -

(i)         Provide claimants at least 60 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;

(ii)        Provide claimants the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;

(iii)       Provide that a 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.  Whether a document, record, or other information is relevant to a claim for benefits shall be determined by reference to paragraph (m)(8) of this section;

(iv)       Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

29 C.F.R. § 2560.503-1(H)(1), (2) (emphasis added). 

Clearly, Kemper did not comply with the procedural safeguards that are such an integral part of ERISA.  The defendant argues that the plaintiff should have requested the documents from Eaton.  However, as argued by the plaintiff’s counsel, he chose not to request the documents from Eaton because he knew that Eaton would be allowed 30 days to provide the documents under 29 U.S.C. § 1132(c), which would make Eaton’s deadline after the September 12, 2002, deadline imposed by Kemper in its letter (Hoskins aff. ¶ 18).  Kemper, as the defendant’s claims administrator, was obligated to provide the Plan documents and internal guidelines to the plaintiff.  The plaintiff notes that Eaton was required under the regulations to produce only the Plan documents if requested, not the internal guidelines, and Eaton could charge for the copies while Kemper was required to provide the copies free of charge.  29 U.S.C. § 1024(b)(4).  Based upon the foregoing, the plaintiff’s counsel reasonably concluded that it was in the best interest of his client to not request the documents from Eaton, as he had already requested the documents on several occasions from Kemper.”  (Emphasis added)

Click here to view the Culbertson decision.