Jacqueline Avery v. Sedgwick Claims Management Services, Inc., et al.

Under Section 503 of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1133, employee benefit plans must, in accordance with the regulations of the Secretary of Labor:

1. provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and

2. afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim. In turn, the Secretary of Labor’s claims procedure regulations, 29 C.F.R. § 2560.503-1, precisely detail the minimum performance standards necessary to comply with the statute. However, the Sixth Circuit has ruled that violations of the claims procedure regulations may be excused under the judicial “substantial compliance” doctrine if a judge determines that plan procedures satisfy the “essential purpose” of Section 503. App. 10-12. The question presented is: Whether the Sixth Circuit erred in holding – in conflict with the Second and Seventh Circuits – that violations of the claims procedure regulations, 29 C.F.R. § 2560.503-1, may be excused under the judicial “substantial compliance” doctrine if a judge determines that plan procedures satisfy the “essential purpose” of Section 503.