Plaintiff Robert DeMoss appeals from an order of the district court in favor of the defendant, Matrix Absence Management, Inc. (Matrix).

As an employee of LSI Logic Corporation, Robert DeMoss was a participant in his employer’s LTD group insurance policy administered by Matrix. On May 10, 2002 Matrix found DeMoss eligible for LTD benefits based on a mental, emotional, or nervous illness. However, Matrix denied LTD benefits due to diabetes complications, cardiac neuropathy, and eye problems. After receiving notice of the decision, DeMoss requested administrative review of the decision, but Matrix never responded.

District Court review

More than seven years later, in December 2010, DeMoss sought review in district court asking the court to award him LTD benefits based on physical disability or to order Matrix to conduct further evidentiary review. The District court ordered Matrix to determine whether DeMoss was eligible for LTD benefits because of his claimed physical disabilities.

The court’s order specifically provided that:

Upon remand to the administrator, Defendant must provide Plaintiff a full and fair review. If Defendant denies Plaintiff’s request for physical long-term disability benefits, Defendant must set forth its reasons and rationale, and allow Plaintiff to submit additional evidence supporting his claim for physical disability benefits. After Defendant has provided its rationale and Plaintiff has submitted additional evidence, if any, Defendant should evaluate Plaintiff’s claim as it would an appeal from an initial denial of benefits. Matrix should render its decision within 120 days from the date of this Order and the decision shall be final for purposed of exhausting remedies.

Matrix denies DeMoss’s claim for LTD benefits for the second time.

The 120-day review period ordered by the court expired on October 8, 2009. By letter dated June 30, 2009 which DeMoss received July 6, Matrix denied DeMoss’s claim for LTD benefits based on physical disability.

DeMoss did not request administrative review or submit additional evidence during the duration of the review period. Instead, on August 20, DeMoss filed a motion with the court to extend the time to seek administrative review explaining that he was not prepared to complete. The court denied the motion on the grounds that it did not have authority to change the plan documents.

DeMoss argues that ERISA regulations required that he have 180 days in which to request an administrative review instead of the court ordered 120-period.

According to ERISA, which governed DeMoss’s group LTD policy, a claimant has 180-days in which to request an administrative review of a claim denial. Nevertheless, the district court denied DeMoss’s motion for further review by Matrix. The court reasoned that because DeMoss had failed to seek review of the adverse benefit determination during the court ordered review period, DeMoss was not entitled to further review.

Court finds DeMoss failed to request a review of Matrix’s benefit-denial decision or to provide Matrix with additional and/or updated medical evidence during the court-ordered 120-day review period.

In its order in favor of Matrix, the district court held that DeMoss had failed to exhaust his administrative remedies and that no exception to the exhaustion requirement applied.

DeMoss subsequently appealed to the United States Court of Appeals for the 10th Circuit arguing that:

  1. the district court was wrong in denying his request for an extension of time to seek administrative review;
  2. the district court was wrong to refuse his request for an order allowing him to exhaust his administrative remedies; and
  3. if he had failed to exhaust his remedies, such failure should be excused because further efforts on his parts would have proven useless.

The Court of Appeals refused to accept any of DeMoss’s arguments. Instead, it agreed with the district court in saying that DeMoss had failed, in the initial appeal of the adverse benefit determination, to argue that Matrix’s plan did not comply with federal regulations. The court therefore reasoned that DeMoss could no longer raise such an argument. Moreover, the court concluded that DeMoss had failed to convince it that his failure to exhaust his remedies should be excused. As such, the court found in favor of Matrix.

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.