United States District Court, E.D. Tennessee, Chattanooga Division
W. Phillips, United States District Judge
matter is before the Court on Plaintiff's Motion for
Judgment on the Pleadings [doc. 50], Plaintiff's Brief in
Support of the Motion [doc. 54], Defendant's Response and
Cross-Motion for Judgment on the Pleadings [doc. 65],
Defendant's Brief in Support of the Cross-Motion [doc.
66], Plaintiff's Reply [doc. 78], Defendant's
Sur-Reply [doc. 84], and Plaintiff's Response to
Defendant's Sur-Reply [doc. 85]. For the reasons herein,
the Court will deny both motions and will remand this action
based on Defendant's contention that Plaintiff has failed
to exhaust her administrative remedies.
2008 and 2009, Plaintiff Beth Nichole Jordan, a nurse
anesthetist, suffered a possible tick bite while camping,
contracted Lyme disease, and began to experience various
medical complications from the disease. [Compl., doc. 1,
¶¶ 8, 12-13; R. at 312, 709-10, 854-56, 1428-31].
She eventually filed for disability benefits under her
employer's long-term disability policy, whose
administrator is Defendant Reliance Standard Life Insurance
Company (“Reliance”). [Compl. ¶¶ 9-11,
14-15; see R. at 317- 22]. Reliance concluded that
she qualified for long-term disability benefits under its
policy, approved her claim, and provided her with benefits.
[Compl. ¶ 16; R. at 303, 1606]. But a few years later,
in 2015, Reliance terminated her benefits after finding that
she did not meet the policy's definition of “Total
Disability.” [Compl. ¶¶ 22-23; R. at 9,
Jordan appealed Reliance's denial of her benefits on
November 3, 2015, through Reliance's internal
appellate-review process. [Compl. ¶ 24; R. at 1214].
While the appeal was ongoing, Reliance sent a letter to Ms.
Jordan on December 16, 2015, informing her that it would
require her to undergo an independent medical examination,
[Compl. ¶ 27; R. at 1621]-which it is free to do under
the policy's terms, [R. at 13]- and that it would
“toll the statutory time frames for rendering an appeal
determination pending completion of the examination and
receipt of the physician's report, ” [id.
at 1622; see Compl. ¶ 37]. Reliance's
third-party vendor scheduled the exam to take place on
January 12, 2016, with Stephen Dawkins, M.D., in Georgia.
[Compl. ¶¶ 27-28; R. at 1335]. On the day of the
exam, while Ms. Jordan was traveling to Dr. Dawkins'
office, Dr. Dawkins had to respond to an emergency. [Compl.
¶ 29; R. at 237]. Although he could not keep his
appointment with Ms. Jordan at the time that they had
originally scheduled, he did offer to see her later in the
afternoon on that same day. [Compl. ¶ 29; R. at 237].
She was unable, however, to meet with him on that day.
[Compl. ¶ 30; R. at 237].
January 29, 2016, Reliance contacted Ms. Jordan's counsel
about rescheduling the appointment. [Compl. ¶ 31; R. at
237]. According to Ms. Jordan, the due date for a decision on
her appeal was December 18, 2015, [Compl. ¶ 35; R. at
243], and her counsel informed Reliance that she was willing
to attend the exam only if Reliance could reschedule it
“quickly, ” [Compl. ¶ 31; R. at 243]. The
earliest available date for another appointment with Dr.
Dawkins, however, was apparently February 24, 2016. [Compl.
¶ 32; R. at 243, 1628].
February 5, 2016, Ms. Jordan, without having received a final
decision from Reliance regarding her appeal, filed suit in
this Court under the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. § 1132(a)(1)(B),
claiming that Reliance wrongfully denied her disability
benefits under the policy and seeking a judgment entitling
her to those benefits. [Compl. at 7-8]. She alleges that
“this matter is now properly before this court for
judicial review.” [Id. ¶ 2].
Specifically, she maintains that “[b]ecause Reliance
Standard has failed to follow the decision timeline required
by the ERISA claims regulations . . . Plaintiff's
administrative remedies are deemed exhausted[.]”
[Id. ¶ 41]. In response, Reliance alleges that
“Plaintiff's claim is barred by her failure to
exhaust her administrative remedies.” [Answer, doc. 5,
permits a participant of certain employee benefit plans to file
a civil action in federal district court for the recovery of
benefits under these plans. 29 U.S.C. § 1132(a)(1)(B),
(e)(1); see also Id. §§ 1002(1),
1003(a)-(b) (defining the types of plans to which ERISA
applies). ERISA, however, “requires a participant to
exhaust his or her administrative remedies prior to
commencing suit in federal court.” Miller v. Metro.
Life Ins. Co., 925 F.2d 979, 986 (6th Cir. 1991).
Although ERISA itself does not expressly require exhaustion,
the Sixth Circuit espouses a judicially created doctrine of
exhaustion based on “[t]he administrative scheme of
ERISA.” Constantino v. TRW, Inc., 13 F.3d 969,
974 (6th Cir. 1994) (quoting id.). A participant can
therefore file suit to recover benefits under ERISA only
after receiving a plan administrator's final decision as
to that participant's entitlement to benefits. See
Heimeshoff v. Hartford Life & Accident Ins. Co., 134
S.Ct. 604, 610 (2013) (“A participant's cause of
action under ERISA accordingly does not accrue until the plan
issues a final denial.”).
participant, however, may also file suit before
receiving a final decision if that decision is untimely under
29 C.F.R. § 2560.503-1(l)(2)(i). Under this
regulation,  which is known as the
“deemed-exhausted provision, ” a court must
construe the administrator's untimeliness as a denial of
benefits and deem the participant's administrative
remedies to be exhausted. 29 C.F.R. §
2560.503-1(i)(1)(i), (i)(3)(i), (l)(2)(i). For a
claim of disability benefits, the administrator's final
decision as whether to uphold an initial denial of benefits
is untimely if it does not take place within forty-five days
of the participant's request for a review, id.
§ 2560.503-1(i)(1)(i), (i)(3)(i)-unless the
administrator provides the participant with written notice of
“special circumstances” that require an extension
of time, id.§
2560.503-1(i)(1)(i). An extension of time due to special
circumstances cannot exceed an additional forty-five days,
meaning that the administrator must render a final decision
no later than ninety days from the participant's request
for a review. Id. § 2560.503-1(i)(1)(i),
Court begins by noting that the exhaustion of administrative
remedies applies only to plan-based claims under ERISA; it is
not an antecedent to a participant's right to bring a
statutory violation of ERISA-like an alleged
violation of ERISA's anti-cutback provisions under 29
U.S.C. § 1054(g) or an alleged violation of ERISA's
fiduciary duties under 29 U.S.C. § 1104. Hitchcock
v. Cumberland Univ. 403(b) DC Plan, 851 F.3d 552, 564
(6th Cir. 2017). Ms. Jordan, however, does not allege a
breach of fiduciary duty or any other statutory violation of
ERISA, asserting only a claim for the wrongful denial of
benefits under the terms of Reliance's policy.
[See Compl. ¶¶ 46-53]. Her satisfaction
of the common-law doctrine of exhaustion is therefore a
prerequisite to her right to maintain this action. Also,
Reliance incorporated the common-law exhaustion requirement
into its policy, which states that “ERISA claim appeal
remedies . . . must be exhausted” before a participant
can pursue review in another forum and provides that all
reviews of claims must be “complete.” [R. at 13];
see Union Sec. Ins. Co. v. Blakeley, 636 F.3d 275,
276 (6th Cir. 2011) (stating that ERISA “repeatedly
underscores the primacy of the written
plan”). So under both the common law and
Reliance's policy, Ms. Jordan had to exhaust her
administrative remedies before filing this action-and she
acknowledges as much by pleading that she has
“exhausted her required administrative
remedies with respect to the long term disability
claim.” [Compl. ¶ 42 (emphasis added)].
although she did not secure a final decision from Reliance by
pursuing its internal appellate-review process to its end,
she nonetheless argues that she has exhausted her
administrative remedies and properly filed suit in this Court
because Reliance never issued a timely final decision under
the applicable deadline. [Id. ¶¶ 2, 35,
39; Pl.'s Br. at 20, 22-25]. She claims that because
Reliance made no decision within forty-five days of her
appeal, she did not have to wait for a decision.
[Id.]. She also asserts that Reliance's letter
from December 16, 2015-in which Reliance notified her of its
intent to schedule an independent exam-does not constitute
written notice of special circumstances and that Reliance was
therefore not entitled to an additional forty-five-day
extension based on this letter. [Compl. ¶ 36; Pl.'s
Br. at 24-25]. In sum, she urges the Court to view her
administrative remedies as exhausted under the
before delving into the issue of exhaustion, the Court must
define the legal parameters for its analysis. Although courts
have resolved ERISA cases through summary judgment and bench
trials, the Sixth Circuit, in a concurring opinion, has
advised courts not to use either procedure in these types of
cases. See Wilkins v. Baptist Sys., Inc., 150 F.3d
609, 617-19 (6th Cir. 1998) (Gilman, J., concurring).
Considering only the evidence that the parties presented to
the administrator, courts should instead review the
administrative record and, based on that review, issue
findings of fact and conclusions of law. Id. at 619.
But as to the specific issue of exhaustion, Reliance-
importantly-does not ask for judgment on the administrative
record; instead, it requests the dismissal of Ms.
Jordan's claim: “Plaintiff . . . failed to exhaust
her administrative remedies ...