Santana-Diaz v. Metropolitan Life Insurance Co

United States Court of Appeals
For the First Circuit
No. 15-1273
DIONISIO SANTANA-DÍAZ,
Plaintiff, Appellant,
v.
METROPOLITAN LIFE INSURANCE COMPANY,
Defendant, Appellee.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Juan M. Pérez-Giménez, U.S. District Judge]
Before
Thompson, Hawkins,* and Barron,
Circuit Judges.
Efrain Maceira-Ortiz for appellant.
Frank Gotay-Barquet for appellee.
March 14, 2016
* Of the Ninth Circuit, sitting by designation.
THOMPSON, Circuit Judge. In this appeal under the
Employee Retirement Income Security Act of 1974 ("ERISA"), as
amended, 29 U.S.C. §§ 1001-1461, Appellant Dionisio Santana-Díaz
("Santana-Díaz") challenges the district court's dismissal of his
suit as time-barred, arguing that he is entitled to equitable
tolling, in part because the plan administrator, Appellee
Metropolitan Life Insurance Company ("MetLife"), failed to include
the time period for filing suit in its denial of benefits letter.
We hold that ERISA requires a plan administrator in its denial of
benefits letter to inform a claimant of not only his right to bring
a civil action, but also the plan-imposed time limit for doing so.
Because MetLife violated this regulatory obligation, the
limitations period in this case was rendered inapplicable, and
Santana-Díaz's suit was therefore timely filed. Accordingly, we
reverse and remand.
BACKGROUND
We begin by summarizing the facts relevant to this
appeal. Santana-Díaz was a financial analyst and ten-plus-year
employee at Shell Chemical Yabucoa, Inc. ("Shell Chemical").1 He
participated in Shell Chemical's employee welfare benefit plan
(the "Plan"), which Shell Chemical provided through a group
1
According to the complaint, Santana-Díaz actually began his
employment with Puerto Rico Sun Oil Company ("SUNOCO") in 1981 as
a clerk, but SUNOCO sold its Yabucoa operations to Shell Chemical
in 2002.
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insurance policy issued by MetLife. Beginning in November 2007,
Santana-Díaz, who suffered from major depression, high blood
pressure, asthma, and various other physical and mental ailments,
claimed and received sick leave and then short-term disability
leave. Santana-Díaz submitted his claim for long-term disability
benefits on April 7, 2008, and in December 2008, received his first
long-term disability benefit payment for the period beginning on
November 23, 2008.
On April 5, 2010, MetLife sent Santana-Díaz a letter
informing him that, although he was currently receiving long-term
disability benefits, the maximum duration period for his
particular disability was twenty-four months, and his benefits
would therefore expire on November 22, 2010. As MetLife explained
it, under the terms of the Plan, long-term disability benefits
were limited to twenty-four months if the beneficiary's disability
was the result of a "mental or nervous disorder or disease
limitation." "[T]he primary diagnosis preventing [Santana-Díaz]
from working [was] major depression," MetLife said, which fell
into that category, thus Santana-Díaz was entitled to long-term
disability benefits only for the limited duration period. MetLife
went on to explain that in order to continue receiving benefits
beyond November 22, 2010, Santana-Díaz would have to submit
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additional documentation that showed his disability was not
subject to the limitation.2
After receiving the April 5, 2010 letter, Santana-Díaz
submitted various medical files and additional information. Upon
reviewing the documents, MetLife denied Santana-Díaz's claim for
an extension of benefits beyond the twenty-four-month limited
period in a letter dated November 24, 2010. Santana-Díaz,
proceeding pro se, filed an administrative appeal of the decision
with the aid of his son, which MetLife likewise denied in an August
19, 2011 letter. Now this is important for our purposes today:
both MetLife's November 24, 2010 initial denial of benefits letter
and its August 19, 2011 final denial letter informed Santana-Díaz
that he could bring a civil action, but neither letter included a
time limit for doing so or mentioned at all that the right to bring
suit was subject to a limitations period.
Nevertheless, the Plan -- which Santana-Díaz had
received when Shell Chemical first became his employer at least
ten years prior -- did contain a three-year limitations period
that provided, in relevant part, that "[n]o legal action of any
kind may be filed . . . more than three years after proof of
Disability must be filed." Under the terms of the Plan, the
2 For example, not all disabilities resulting from "mental or
nervous disorder or disease" were limited to twenty-four months;
the Plan made an exception for schizophrenia, bipolar disorder,
dementia, and organic brain disease.
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deadline for Santana-Díaz's proof of disability had been February
17, 2009 (and no, MetLife never mentions this start date in its
letters either).3 According to MetLife, Santana-Díaz's time period
for filing suit therefore expired three years thereafter.
Alas, Santana-Díaz, finally represented by counsel, did
not file suit until August 18, 2013. The complaint alleged a 29
U.S.C. § 1132(a) claim for improper denial of benefits. In a
motion for summary judgment, MetLife argued the suit was filed a
year-and-a-half too late. The district court agreed, granting the
motion and dismissing Santana-Díaz's complaint as time-barred.
Santana-Díaz now appeals, arguing that the district court erred in
dismissing his case because MetLife's failure to provide notice of
the time limit for filing suit in its final denial letter entitled
him to equitable tolling.
3 The route by which this February 17, 2009 proof-of-
disability deadline is arrived at, while undisputed by the parties,
is labyrinthine. Under the Plan, proof of disability is due
"within 3 months after the end of [the] Elimination Period," which,
in turn, is defined as "360 days of continuous Disability," during
which long-term disability benefits are not paid, beginning on the
day the beneficiary becomes disabled. Here, the Elimination Period
began on November 28, 2007, when Santana-Díaz became disabled, and
ended 360 days thereafter. By our calculations, this would have
been November 22, 2008, but the parties, without explanation, agree
that the Elimination Period ended on November 17, 2008. Accepting
the parties' computation, Santana-Díaz's proof of disability was
then due three months after that November 17, 2008 date. Hence,
February 17, 2009.
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DISCUSSION
We review the district court's grant of summary judgment
de novo. Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 516
(1st Cir. 2005).
ERISA itself does not contain a statute of limitations
for bringing a civil action, see 29 U.S.C. § 1132(a)(1)(B), so
federal courts usually "borrow the most closely analogous statute
of limitations in the forum state." Santaliz-Ríos v. Metro. Life
Ins. Co., 693 F.3d 57, 59 (1st Cir. 2012), cert. denied, 133 S.
Ct. 1726 (2013). But where the employee benefit plan "itself
provides a shorter limitations period, that period will govern as
long as it is reasonable." Id. at 60. In this case, the Plan
contained a three-year limitations period that ran from the date
proof of disability was due. MetLife included no mention of this
time limit in its final denial letter. The issue at the heart of
this appeal is what impact such defective notice should have on a
contractual limitations period. Before we turn to this question,
however, we first briefly address Santana-Díaz's argument that the
district court applied the wrong start date to the limitations
period.4
4 MetLife raises a preliminary argument that we should
summarily dismiss Santana-Díaz's appeal because his brief does not
technically comply with Federal Rule of Appellate Procedure
28(a)(6) in that it does not contain a statement of facts or
citations to the record. We are none too pleased that Santana-
Díaz's brief, indeed, lacks a separate statement of facts section
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I. Limitations Period Start Date
Santana-Díaz's argument regarding the limitations period
start date is anything but clear. He seems to want us to conclude
that the three-year limitations period began to run on August 19,
2011, the date of the final denial letter, and not, as the Plan
provides, on the date proof of disability was due.
Santana-Díaz argues that, because he was still receiving
benefits on February 17, 2009, when proof of disability was due,
he "had nothing to complain about," and had no reason to file suit.
Thus, he says, it would be "clearly erroneous, patently
unreasonable and will result in an unfair outcome" for the
limitations period to have begun to run before he had suffered an
actual injury. Santana-Díaz seems to suggest that perhaps the
limitations period would, instead, have begun to run on November
24, 2010, when MetLife issued notice terminating his benefits.
Except that date did not set off the limitations period either, he
argues, because in that November 24, 2010 letter, MetLife stated:
"In the event your appeal is denied in whole or in part, you will
have the right to bring a civil action . . . ." Santana-Díaz
and record citations, but we will not dismiss the case for these
oversights. Although they are intermingled throughout his brief,
Santana-Díaz provides an adequate description of the relevant
facts, and this case is neither so fact-heavy nor record-intensive
that we are unable to locate the relevant facts in the record. We
therefore reject MetLife's argument that the appeal should be
dismissed on these grounds and proceed to the merits of the appeal.
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argues that this instruction to await the outcome of the
administrative appeal before bringing a civil action, without any
other mention in the letter of a time limit for filing suit,
obscured from him the fact that the clock for filing was already
ticking, and that, on that basis, we should conclude the
limitations period actually only began to run on August 19, 2011,
when his administrative appeal was denied. (Three years from
either date, November 24, 2010, or August 19, 2011, though, would
have rendered Santana-Díaz's August 18, 2013 complaint timely.)
Santana-Díaz never really clarifies in his brief whether
he is challenging the enforceability of the limitations provision,
raising an estoppel argument, or presenting some combination
thereof, and we are not quite persuaded that, under any of these
theories, Santana-Díaz would be able to get around the limitations
period start date as it is written in the Plan.5 Regardless, it
5 The Supreme Court has already held enforceable a contractual
limitations period that, as in the present case, commenced when
proof of disability was due, instead of the date of the final
denial letter, explaining that "[a]bsent a controlling statute to
the contrary, a participant and a plan may agree by contract to a
particular limitations period, even one that starts to run before
the cause of action accrues, as long as the period is reasonable."
Heimeshoff v. Hartford Life & Accident Ins. Co., 134 S. Ct. 604,
610 (2013). Santana-Díaz does not challenge the reasonableness of
either the three-year period on its face or the six months that
were left for filing suit once MetLife issued a final decision.
Instead, he suggests his case is distinguishable because, unlike
the plaintiff in Heimeshoff who was initially denied her claim, he
was receiving benefits at the time the limitations period began to
run. But Santana-Díaz cites no legal authority that explains why
this should make a difference in our analysis, nor do we find his
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does not matter because, as we get to in a minute, we conclude
MetLife's regulatory violation rendered the contractual
limitations period in this case altogether inapplicable, and we
therefore do not need to decide when that limitations period would
have begun to run.
II. MetLife's Regulatory Violation
Santana-Díaz argues here, as he did below, that
MetLife's final denial letter did not comply with 29 C.F.R.
§ 2560.503-1(g)(1)(iv) because it failed to provide notice of the
plan-imposed time limit for filing suit, and that, as a result,
equitable tolling should apply.6 The district court disagreed,
argument convincing. Although the plaintiff in Heimeshoff never
received benefits, she was equally unable to file suit until her
claim was administratively exhausted. Yet, the Supreme Court found
it fit to hold that the limitations period continued to run during
this time, despite the fact that her administrative appeal had not
yet been denied and she could not have filed her action until the
final denial. See id. at 612-13.
As to equitable estoppel, that doctrine applies when a
defendant makes a "definite misrepresentation," on which it has
reason to know the plaintiff will rely, and the plaintiff
reasonably relies on it in failing to bring suit. Ramírez-Carlo
v. United States, 496 F.3d 41, 49 (1st Cir. 2007) (quoting Heckler
v. Comty. Health Servs., 467 U.S. 51, 59 (1984)). While MetLife's
November 24, 2010 letter may have been confusing, we are not
certain that its statements would amount to a "misrepresentation,"
or that Santana-Díaz reasonably relied on it to late-file his suit.
6A limitations period may be equitably tolled where a
plaintiff establishes that "extraordinary circumstances" beyond
his control prevented a timely filing, such as where the plaintiff
was "materially misled into missing the deadline." Barreto-
Barreto v. United States, 551 F.3d 95, 101 (1st Cir. 2008)
(citations omitted).
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concluding that, even though MetLife had failed to provide notice,
this failure did not entitle Santana-Díaz to the "extraordinary
measure of equitable tolling" because Santana-Díaz "was made aware
of both the time limit for plan participants to file legal action
and how the plan calculates time, since these matters were clearly
and explicitly laid out in the group policy." We need not
determine whether the district court correctly decided this
equitable tolling issue, however, because we begin and end our
review with the issue of MetLife's failure to note the time period
for filing suit in its final denial letter.
As we explain in the following sections, we conclude
that, in failing to provide such notice, MetLife was not in
substantial compliance with the ERISA regulations, and that this
rendered the limitations period altogether inapplicable. Because
this resolves the question of whether Santana-Díaz's claim was
time-barred, we need not discuss whether the limitations period
would otherwise have been equitably tolled.7
7 At oral argument, counsel for MetLife argued we could not
directly address the argument that it had violated section
2560.503-1(g)(1)(iv) because the only question Santana-Díaz had
raised on appeal is whether he would be entitled to equitable
tolling as a result of the purported violation. But we are
unpersuaded by the suggestion that Santana-Díaz has waived the
regulatory violation argument here. To the contrary, Santana-Díaz
explicitly argued in his brief, as he did before the district
court, that MetLife violated section 2560.503-1(g)(1)(iv) when it
failed to include the time period for filing suit in its final
denial letter. Specifically, he argued: "First, the final notice
served by MetLife did not include the statement of the time frame
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A. Violation of Section 2560.503-1(g)(1)(iv)
ERISA is a remedial statute intended "to 'protect . . .
the interests of participants in employee benefit plans and their
beneficiaries' by setting out substantive regulatory requirements
for employee benefit plans and to 'provid[e] for appropriate
remedies, sanctions, and ready access to the Federal courts.'"
Aetna Health Inc. v. Davila, 542 U.S. 200, 208 (2004) (alterations
in original) (quoting 29 U.S.C. § 1001(b)). In furtherance of
this purpose, section 503 of ERISA, codified as 29 U.S.C. § 1133,
provides that "every employee benefit plan shall . . . provide
adequate notice in writing to any participant or beneficiary whose
plaintiff had to file the civil action as required by ERISA
regulations contained [in] 29 CFR 2560.503-1(g)[1](iv);" and, "The
other issue has to do with appellee's violation [of] the notice
requirement imposed by ERISA. According to ERISA
regulations . . . on its final notice MetLife had the legal
obligation to notify plaintiff of the time limit to file court
action;" and again in his Reply Brief, "Accepting appellee's
argument amounts to converting [to] 'dead letter' the notice
requirement contained in 29 CFR 560.503-1(g)[1](iv)." Thus, we
think the regulatory violation argument was sufficiently briefed.
See United States v. Dunbar, 553 F.3d 48, 63 n.4 (1st Cir. 2009)
(holding that, although an argument was not stated "artfully," it
was not waived where the brief identified the relevant facts and
law).
Furthermore, MetLife had and took the opportunity to respond,
albeit briefly, to this argument, indicating that it understood
Santana-Díaz was challenging its failure to comply with section
2560.503-1(g)(1)(iv). (We note that MetLife, moreover, was the
defendant-appellee in Moyer v. Metropolitan Life Insurance Co.,
762 F.3d 503 (6th Cir. 2014), a nearly identical case in which, as
we discuss later, the Sixth Circuit took a similar approach as the
one we take here. MetLife was thus certainly aware of the way
other circuits have treated this exact regulatory violation.)
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claim for benefits under the plan has been denied" and "afford a
reasonable opportunity . . . for a full and fair review by the
appropriate named fiduciary of the decision denying the claim."
29 U.S.C. § 1133. One of the purposes of section 1133 is to
"enable the claimant to prepare adequately for any further
administrative review, as well as appeal to the federal courts."
Witt v. Metro. Life Ins. Co., 772 F.3d 1269, 1280 (11th Cir. 2014)
(citation omitted); see also Brown v. J.B. Hunt Transp. Servs.,
Inc., 586 F.3d 1079, 1086 (8th Cir. 2009); Halpin v. W.W. Grainger,
Inc., 962 F.2d 685, 689 (7th Cir. 1992). As such, the regulations
promulgated under section 1133, in relevant part, require a plan
administrator to provide "written or electronic notification of
any adverse benefit determination" that includes a "description of
the plan's review procedures and the time limits applicable to
such procedures, including a statement of the claimant's right to
bring a civil action." 29 C.F.R. § 2560.503-1(g)(1)(iv).
The question before us is one of interpretation: the
parties differ in their reading of this regulation, specifically,
in their interpretation of which "time limits" must be included in
the denial letter. Santana-Díaz argues the regulation requires
plan administrators to include notice of not only the right to
bring a civil action, but also the time limit for filing the
action. MetLife disagrees. It suggests we should read the
regulation as requiring only those time limits applicable to
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internal administrative review procedures. In other words,
MetLife seems to argue that the two phrases in section 2560.503-
1(g)(1)(iv) could be read separately, such that a plan
administrator is, first, required to include in its denial letter
a "description of the plan's review procedures and the time limits
applicable to such procedures," and second, required to include "a
statement of the claimant's right to bring a civil action," though
not necessarily the time period for filing the action.
In support of its interpretation of section 2560.503-
1(g)(1)(iv), MetLife cites an unpublished case, Wilson v. Standard
Insurance Co., 613 F. App'x 841 (11th Cir. 2015) (per curiam), in
which the plan administrator similarly failed to include notice of
the time limit for filing suit in its final denial letter. But in
Wilson the Eleventh Circuit did not decide on an interpretation of
section 2560.503-1(g)(1)(iv). Instead, it concluded the language
was ambiguous, and speculated the provision could be read two ways:
either as including "civil action" as part of the plan's review
procedures, such that notice of the time limits for both
administrative review procedures and civil actions are required,
or as requiring notice of the right to file suit, but not the time
limits for doing so. Id. at 844. Rather than deciding on an
interpretation, the court assumed, favorably to the plaintiff,
that the plan administrator had violated section 2560.503-
1(g)(1)(iv), but declined to "simply assume unenforceability" of
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the limitations period on the basis of the plan administrator's
"failure to interpret the ambiguous regulation that way." Id. It
thus resolved the case against the plaintiff on equitable tolling
grounds instead, holding that she was not entitled to equitable
tolling because she had not been diligent in pursuing her suit,
and it thus concluded that the case had been properly dismissed as
time-barred. Id. at 844-45.
We decline to follow the Eleventh Circuit's approach
here. Based on the plain language of the regulation, we hold that
the correct interpretation of section 2560.503-1(g)(1)(iv) is that
a denial of benefits letter must include notice of the plan-imposed
time limit for filing a civil action. To repeat, the regulation
states that the letter must contain a "description of the plan's
review procedures and the time limits applicable to such
procedures, including a statement of the claimant's right to bring
a civil action." 29 C.F.R. § 2560.503-1(g)(1)(iv) (emphasis
added). We previously noted in Ortega Candelaria v. Orthobiologics
LLC, 661 F.3d 675, 680 n.7 (1st Cir. 2011), a case in which we
discussed but did not decide this issue, that we think "the term
'including' indicates that an ERISA action is considered one of
the 'review procedures' and thus notice of the time limit must be
provided." We further stated we would not find "compelling" the
alternative reading, discussed in Wilson, that "notice of the right
to sue under ERISA is in addition to, and divorced from, notice of
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review procedures and the time frame pertaining to such
procedures." Id. Indeed, interpreting the regulation that
way -- as imposing two unrelated requirements -- would require us
effectively to erase the word "including" from the sentence and to
replace it with "and," such that the regulation would read: "The
notification shall set forth . . . a description of the plan's
review procedures and the time limits applicable to such
procedures, [and] a statement of the claimant's right to bring a
civil action . . . ." 29 C.F.R. § 2560.503-1(g)(1)(iv). It would
then further require us to determine that a plan's time limit for
filing, itself, could not otherwise be included as one of the
"plan's review procedures," or alternatively, that a civil action
could not otherwise be one of the "plan's review procedures," for
which time limits must be included. We will not interpret the
regulation in a way that so contravenes the text, and not even the
Eleventh Circuit in Wilson, to which MetLife cites, has done so.
On the other hand, both the Third and Sixth Circuits
have interpreted section 2560.503-1(g)(1)(iv) as we do today, and
have held that the regulation requires a plan administrator to
provide in its final denial letter not only notice of the right to
bring a civil action, but also of the time limit for filing the
action. In Mirza v. Insurance Administrator of America, Inc., 800
F.3d 129 (3d Cir. 2015), the Third Circuit reasoned that the word
"including" was the "most important word in the sentence" for
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purposes of interpreting the regulation, and that it signified
that "civil actions are logically one of the review procedures
envisioned by the Department of Labor." Id. at 134. The court
therefore concluded that "29 C.F.R. § 2560.503–1(g)(1)(iv)
requires that adverse benefit determinations set forth any plan-
imposed time limit for seeking judicial review." Id. at 136.
Likewise, in Moyer v. Metropolitan Life Insurance Co., 762 F.3d
503 (6th Cir. 2014), the Sixth Circuit concluded, based on the
phrase, "including a statement of the claimant's right to bring a
civil action," 29 C.F.R. § 2560.503-1(g)(1)(iv) (emphasis added),
that "[t]he claimant's right to bring a civil action is expressly
included as a part of those procedures for which applicable time
limits must be provided," and thus held that denial letters must
include the time limit for judicial review. Id. at 505.8
8 We note that it could feasibly be argued that section
2560.503-1(g)(1)(iv)'s notice requirement applies only to initial
denial of benefits letters. The regulations contain a later
subsection that governs the "[m]anner and content of notification
of benefit determination on review," 28 C.F.R. § 2560.503-1(j)
(emphasis added), which appears to apply specifically to final
denial letters. That subsection mandates that a "plan's benefit
determination on review" must include, among other things, "a
statement of the claimant's right to bring an action under section
502(a) of the Act," id. § 2560.503-1(j)(4), but makes no express
reference to the requirement to include the time limit for filing
the action. Thus, one could make the argument that plan
administrators are required to include notice of the time limit
for filing suit in the initial denial of benefits letter, only.
Here, the parties make no mention of section 2560.503-1(j)(4) in
their briefs, and treat section 2560.503-1(g)(1)(iv) as applying
to final denial letters, as we did in Ortega Candelaria v.
Orthobiologics LLC, 661 F.3d 675, 677-78 (1st Cir. 2011), and as
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Our reading of the regulation is furthermore in keeping
with 29 U.S.C. § 1133's purpose of ensuring a fair opportunity for
judicial review, and with ERISA's overall purpose as a remedial
statute. Claimants are obviously more likely to read information
stated in the final denial letter, as opposed to included (or
possibly buried) somewhere in the plan documents, particularly
since, as was the case here, plan documents could have been given
to a claimant years before his claim for benefits is denied. The
Department of Labor, recognizing this, has required that the denial
letters themselves include certain information that the Department
has deemed critical to ensuring a fair opportunity for review.9
We think it clear that the Department has included the plan-imposed
time limit for filing suit among this required information.10
other circuits have, see Mirza v. Ins. Admin. of Am., Inc., 800
F.3d 129, 135-36 (3d Cir. 2015); Moyer, 762 F.3d at 504. Thus,
for purposes of this case, we assume section 2560.503-1(g)(1)(iv)
applies to final denial letters. (It makes no difference in this
case because neither MetLife's November 24, 2010 initial denial of
benefits letter nor its August 19, 2011 final denial letter was in
compliance with section 2560.503-1(g)(1)(iv).)
9 In addition to a description of the plan's review procedures
and applicable time limits, which is the provision at issue here,
the regulations also require that the final denial letters include
the specific reasons for the adverse determination, the plan
provisions on which the adverse determination is based, and any
additional information necessary to perfect the claim. 29 C.F.R.
§ 2560.503-1(g)(1)(i)-(iii).
10 Section 2560.503-1(g)(1)(iv)'s notice requirement is made
all the more important where an employee benefit plan contains a
contractual limitations period that, though legally enforceable,
seems designed to confuse. Such is the case here. The limitations
period began to run on the proof of disability deadline -- the
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Thus, we hold that MetLife had a regulatory obligation
to provide notice of the time limit for filing suit in its denial
of benefits letter, and it failed to do so. Our holding is limited
to the circumstances of the case before us, in that it applies
only to plan-imposed time limits for filing suit. We reserve for
another day the question of the extent of a plan administrator's
obligation, under section 2560.503-1(g)(1)(iv), to provide, where
the plan itself does not contain a contractual limitations period,
notice of the forum state's applicable statute of limitations.
Having determined that MetLife violated section
2560.503-1(g)(1)(iv), we turn our attention to whether Santana-
Díaz was prejudiced by the violation.
B. Prejudice
Our case law does not always require strict technical
compliance with the regulations -- all that is required of the
plan administrator is "substantial compliance" with the spirit of
complicated calculation for which we have already described --
while Santana-Díaz was still receiving benefits, and before he was
informed he would be eligible for those benefits for only a twenty-
four-month period. The period then continued to run while Santana-
Díaz administratively appealed the decision to deny an extension
of his benefits, and it expired just six months after MetLife's
final decision. If employers are to enjoy such "large leeway" in
designing their employee benefit plans, Black & Decker Disability
Plan v. Nord, 538 U.S. 822, 833 (2003), the other side of the coin
is that plan administrators have a duty, under section 1133's
regulations, to be forthcoming about the contractual time limits
that apply to the plan's procedures, so that claimants have a fair
opportunity to pursue administrative and judicial review.
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the regulations. Niebauer v. Crane & Co., Inc., 783 F.3d 914, 927
(1st Cir. 2015). Thus, in cases involving a plan administrator's
regulatory violation, we have tended to require the plaintiff to
demonstrate that the violation prejudiced him by affecting review
of his claim. In other words, a plaintiff must make some "showing
that a precisely correct form of notice would have made a
difference." Recupero v. New England Tel. & Tel. Co., 118 F.3d
820, 840 (1st Cir. 1997).
Here, we must first decide whether to remand to the
district court for a prejudice finding in the first instance, or
make such a determination ourselves. Generally, where a district
court has made a prejudice determination, our case law has treated
it as a "factual conclusion that we review only for clear error."
DiGregorio v. Hartford Comprehensive Emp. Benefit Serv. Co., 423
F.3d 6, 13, 15-16 (1st Cir. 2005). But where the lower court has
made no factual finding as to prejudice, and where one could be
made on the basis of the administrative record before us, we have,
without remanding, made our own prejudice determination. See Bard
v. Boston Shipping Ass'n, 471 F.3d 229, 241 & n.15 (1st Cir. 2006).
In this case, because we conclude that a defective denial letter
that fails to include the limitations period for filing suit is
per se prejudicial, we see no need to remand to the district court
for a factual finding as to prejudice.
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As we have already noted, the Department of Labor
requires plan administrators to give notice of the limitations
period in the denial of benefits letter -- even when the
information is also contained elsewhere in the plan documents, and
regardless of when the claimant last received a copy of the plan
documents -- because it recognizes that it is the denial of
benefits letter that most clearly and readily provides the
plaintiff with the information he needs to know to pursue review
of his claim. This leaves us with but one conclusion to draw,
which is that the regulation itself contemplates that failure to
include this information in the denial of benefits letter is per
se prejudicial to the plaintiff. Obviously, a plan administrator's
compliance with its regulatory obligation to give this notice in
its denial of benefits letters "ma[kes] a difference," Recupero,
118 F.3d at 840, because it notifies a claimant of the pending
deadline for filing his case.11 And ERISA's purpose of ensuring
11 Furthermore, we see no value in requiring lower courts to
make an individualized factual finding of actual prejudice in cases
involving this particular regulatory violation. Unlike in other
notice defect cases where it might be possible for a plaintiff to
prove actual prejudice, there is no way for a plaintiff to prove
prejudice from a plan administrator's failure to include the
limitations period in the final denial letter, other than by merely
attesting that he would have timely filed had he only received
proper notice. By contrast, in Terry v. Bayer Corp., 145 F.3d 28,
38-39 (1st Cir. 1998), we assumed, without deciding, that the plan
administrator had failed to comply with ERISA when it directed the
claimant to forward "any information which may affect the decision
to terminate [his] claim," instead of informing him of the specific
documentation or medical reports needed to obtain a favorable
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that claimants have a fair chance to present their cases remains
"the lodestar in determining whether there has been substantial
compliance with the notice provisions." Niebauer, 783 F.3d at
927. Thus, we hold that, where a plan administrator fails, as
MetLife did here, to include the time limit for filing suit in its
denial of benefits letter, and it has not otherwise cured the
defect by, for example, informing the claimant of the limitations
period in a subsequent letter that still leaves the claimant
sufficient time to file suit, the plan administrator can never be
in substantial compliance with the ERISA regulations, and the
violation is per se prejudicial to the claimant. See Moyer, 762
F.3d at 507 ("The exclusion of the judicial review time limits
from the adverse benefit determination letter was inconsistent
with ensuring a fair opportunity for review and rendered the letter
not in substantial compliance."); Mirza, 800 F.3d at 136 ("Without
decision. There, the plaintiff could presumably have shown
prejudice by showing that he actually possessed additional, un-
submitted medical documents, and that the outcome in his case might
have been different had the letter only informed him that they
were needed. Similarly, in Recupero v. New England Telephone &
Telegraph Co., 118 F.3d 820, 825, 840-41 (1st Cir. 1997), where
the claimant argued that the plan administrator failed to include
the specific reasons for denying her claim or cite the specific
plan provisions upon which the denial was based, the claimant could
have presented evidence in the form of additional documents that
she might have submitted if the letter had only made clear their
potential relevance to the denial of her claim. Here, the
violation is obviously and necessarily prejudicial to the
plaintiff, and there is no such corollary evidence of prejudice
that we might expect a plaintiff to proffer.
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[the] time limit, a notification is not in substantial compliance
with ERISA.").12 MetLife's defective notice therefore prejudiced
Santana-Díaz.
C. Remedy
This leaves us with the question of the appropriate
consequence for MetLife's regulatory violation. The parties
dispute whether equitable tolling of the limitations period should
be the remedy for a section 2560.503-1(g)(1)(iv) violation. Our
review today, however, does not reach the equitable tolling
question because we conclude that MetLife's failure to include the
time limit in the final denial letter rendered, as a matter of
law, the contractual three-year limitations period altogether
inapplicable.
Harkening back to our earlier discussion of Mirza and
Moyer, we note that our sister courts in the Third and Sixth
Circuits have resolved cases involving the same regulatory
violation MetLife has committed here by concluding that the
violation rendered the limitations period inapplicable. We think
12Instead of requiring, as we do, that the plaintiff establish
prejudice, courts in the Third and Sixth Circuits appear to apply
a substantial compliance test in which the courts determine whether
the communications between the administrator and participant, as
a whole, fulfill section 1133's requirements. See, e.g., Wenner
v. Sun Life Assurance Co. of Canada, 482 F.3d 878, 882 (6th Cir.
2007); Morningred v. Delta Family-Care & Survivorship Plan, 790 F.
Supp. 2d 177, 194-95, aff'd, 526 F. App'x 217 (3d Cir. 2013).
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their approach is the correct one.13 For example, in Mirza, the
Third Circuit focused its analysis on the plan administrator's
regulatory violation of failing to include the plan's time limit
in its final denial letter, and explained, "we do not find
equitable tolling to be an obstacle, or even relevant, to [the
plaintiff's] claim." 800 F.3d at 133. It concluded that
"[b]ecause the denial letter [the plaintiff] received on August
12, 2010 did not comply with the regulatory requirements, the one-
year deadline for judicial review was not triggered," id. at 137-
38 -- in other words, it would not apply. To do otherwise, the
court reasoned, "would render hollow the important disclosure
function of § 2560.503-1(g)(1)(iv)," as plan administrators would
then "have no reason at all to comply with their obligation to
include contractual time limits for judicial review in benefit
denial letters." Id. at 137.
Similarly, in Moyer, after concluding that "[the
plaintiff] was denied his right to judicial review as a result of
MetLife's failure to comply with § 1133," the Sixth Circuit
reversed the district court's dismissal on timeliness grounds and
13As we have already discussed, the Eleventh Circuit also
encountered a similar scenario in Wilson v. Standard Insurance
Co., 613 F. App'x 841, 843 (11th Cir. 2015) (per curiam), but
decided the case on equitable tolling grounds. Because our reading
of section 2560.503-1(g)(1)(iv) differs from the Eleventh
Circuit's, and because we do not reach the equitable tolling issue
here, we do not find much persuasive weight in this unpublished
case.
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remanded, reasoning that "[t]he appropriate remedy is to remand to
the district court so that [the plaintiff] may now receive judicial
review." 762 F.3d at 507.
The courts' reasoning in Mirza and Moyer makes sense,
given that plan administrators are in the best position to know
what plan-imposed time limits apply to the very plans they are
charged with administering, and that the requirement to include
such information in their denial letters imposes upon them the
most minimal of burdens. To accept that plan administrators may
nevertheless dodge this simple regulatory obligation so long as
claimants have received the plan documents at some point during
their tenure as employees, would, as Santana-Díaz argues,
effectively make section 2560.503-1(g)(1)(iv) "dead letter."
Furthermore, this approach, as the Third Circuit also
discussed in Mirza, is in keeping with analogous ERISA cases in
the administrative review context where courts have declined to
enforce contractual limitations periods on account of a non-
compliant termination of benefits letter. In those cases, the
courts reasoned that a plan administrator's failure to comply with
the ERISA regulations by not providing notice of the time limit
for filing an administrative appeal rendered the limitations
period for administrative review un-triggered. See, e.g., Burke
v. Kodak Ret. Income Plan, 336 F.3d 103, 107 (2d Cir. 2003) ("A
written notice of denial must be comprehensible and provide the
- 24 -
claimant with the information necessary to perfect her claim,
including the time limits applicable to administrative review. A
notice that fails to substantially comply with these requirements
does not trigger a time bar contained within the plan." (citation
omitted)), overruled on other grounds by CIGNA Corp. v. Amara, 563
U.S. 421 (2010); Syed v. Hercules, Inc., 214 F.3d 155, 162 (3d
Cir. 2000) (same); White v. Jacobs Eng'g Grp. Long Term Disability
Benefit Plan, 896 F.2d 344, 350 (9th Cir. 1989) (same). This has
been the case even where the plaintiff possessed a copy of the
plan documents, and therefore was on notice of the time limit for
filing an administrative appeal. See Epright v. Envtl. Res. Mgmt.,
Inc. Health & Welfare Plan, 81 F.3d 335, 342 (3d Cir. 1996) ("The
fact that [the plaintiff's] attorney had a copy of the Plan, and
thus the means to ascertain the proper steps for requesting review,
in no way excuses [the defendant's] failure to comply with the
Department of Labor's regulations.").
Accordingly, we hold that, as a consequence of MetLife's
failure to include the time limit for filing suit in its final
denial letter, the limitations period in this case was rendered
inapplicable.
D. Statute of Limitations
Recall that in the absence of a contractual limitations
period within the employee benefit plan itself, the forum state's
most closely analogous statute of limitations applies to ERISA
- 25 -
claims. Santaliz-Ríos, 693 F.3d at 59. Here, the Plan's
limitations period was rendered inapplicable, so we look to Puerto
Rico law for the closest statute of limitations. See Mirza, 800
F.3d at 137-38 (borrowing state statute of limitations for contract
claims where the plan administrator's regulatory violation
rendered the plan's limitations period not triggered). Because an
ERISA claim brought under 29 U.S.C. § 1132(a) to recover benefits
arises out of a contract between an employer and its employees,
courts in Puerto Rico have applied Puerto Rico's default fifteen-
year statute of limitations for contract claims, P.R. Laws Ann.
tit. 31 § 5294. Santaliz-Ríos, 693 F.3d at 59-60 (citing Nazario
Martinez v. Johnson & Johnson Baby Prods., Inc., 184 F. Supp. 2d
157, 159-62 (D.P.R. 2002)); see also Riley v. Metro. Life Ins.
Co., 744 F.3d 241, 244 (1st Cir. 2014) (applying Massachusetts
statute of limitations for breach of contract to a section 1132(a)
claim), cert. denied, 135 S. Ct. 94; Drinkwater v. Metro. Life
Ins. Co., 846 F.2d 821, 826 (1st Cir. 1988) (stating that an ERISA
claim to enforce benefits is a "simple contract claim"), cert.
denied, 488 U.S. 909.14 The fifteen-year statute of limitations
14 The circuits that have decided this issue appear to
uniformly apply the state statute of limitations for contract
actions. See, e.g., Santino v. Provident Life & Accident Ins.
Co., 276 F.3d 772, 776 (6th Cir. 2001); Wetzel v. Lou Ehlers
Cadillac Grp. Long Term Disability Ins. Program, 222 F.3d 643, 648
(9th Cir. 2000) (en banc); Harrison v. Digital Health Plan, 183
F.3d 1235, 1241 (11th Cir. 1999) (per curiam); Hogan v. Kraft
Foods, 969 F.2d 142, 145 (5th Cir. 1992); Wright v. Southwestern
- 26 -
began to run on August 19, 2011 (the date of the final denial
letter). See Riley, 744 F.3d at 244-45 (explaining that "[w]hile
state law governs the length of the limitations period, federal
common law determines when an ERISA claim accrues," which is
"ordinarily . . . when a fiduciary denies a participant benefits"
(citations omitted)).
Santana-Díaz filed suit on August 18, 2013, which is
well within the fifteen years. Thus, this case was timely filed.
CONCLUSION
For the reasons we explain above, we reverse and remand
for further proceedings consistent with this opinion. Costs to
appellant.
Bell Tel. Co., 925 F.2d 1288, 1291 (10th Cir. 1991); Johnson v.
State Mut. Life Assurance Co. of Am., 942 F.2d 1260, 1263 (8th
Cir. 1991) (en banc).
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