A recent ruling from a federal court in Ohio discusses the interplay between the “deemed exhausted” provision of the ERISA claim regulations – 29 C.F.R. Sec. 2560.503-1(l) – and claim administrators’ requests to “toll” the clock on when claim appeals have to be decided. In Gay v. National Rural Electric Cooperative Association Group Benefits Program, 2014 WL 5475284 (S.D.Ohio October 29, 2014), the court determined that if additional information is requested, the request must be made within the initial period permitted under the ERISA claim regulations. The court further ruled that tolling ends when the claimant responds, regardless of whether the claim administrator considers the response inadequate. Finally, the court ruled that tolling will never extend the deadline for deciding claims beyond the extension permitted in the regulations.
This is a very timely decision since we have been seeing an increasing number of tolling requests for additional information, for examinations, and for other purposes. By ruling that the tolling request must be made within the initial 45 day period, and by maintaining the 90 day maximum period, the court has clarified this issue in a way that will require claim administrators to be more diligent in reviewing claim appeals earlier, and which will give claimants more ammunition to resist last minute “hail Mary” requests for information or examinations that are blatantly intended to defeat meritorious claim appeals. Delaying the claim appeal process for what are arguably irrelevant and unnecessary requests creates a significant hardship on claimants who are already without the support of disability payments necessary to meet living expenses, or in the case of medical claims, the delay could be critical to the claimant’s health.