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Employee Awarded Benefits Due to Employer’s Flawed Administrative Procedures

On Behalf of | Apr 19, 2018 |

In Frye v. Metropolitan Life Insurance Co., a federal district court in Arkansas has held that an employee is entitled to proceeds from dependent life and accidental death and dismemberment (AD&D) insurance policies, despite the fact that her son was ineligible for such coverage due to his age at the time of his death.

Facts. The employee provided her son’s birthdate and other pertinent information when she enrolled him in the employer’s medical plan in 2012. At that time, the employee also elected dependent life and AD&D coverage for her son, but she was not required to provide any information for that coverage.

The son’s coverage under the employer’s dependent life and AD&D insurance policies began in 2013 and automatically renewed in 2014 and 2015. Although her son lost eligibility for coverage when he turned twenty-three years old in 2014, the employee did not notify the employer or the insurer. Moreover, neither the employer nor insurer alerted the employee that her son had aged out of coverage, and they continued to deduct premiums for the coverage from her wages.

After her son’s death in 2015, the employee filed a claim for life and AD&D benefits with the insurer. Acting as the plan’s claims administrator, the insurer denied the employee’s claim, explaining that the policies only covered dependents less than 23. The insurer subsequently concluded that the decedent was ineligible for coverage during the 2015 plan year, and the employer refunded the premiums collected from the employee after the decedent had turned 23.

The employee appealed the adverse benefit determination, and the insurer upheld its decision to deny benefits. In turn, the employee sued the employer in federal court under the provisions of ERISA.

District Court. In reviewing the case, the court found that the evidence presented confirmed that the insurer had correctly denied benefits under the plan provisions, since the policy unambiguously terminated dependent eligibility at age 23.

The court next reviewed whether the employee was entitled to appropriate equitable relief under ERISA. The court concluded that the employer and insurer had breached their fiduciary duties by using flawed administrative procedures that failed to confirm eligibility for coverage, thereby allowing employees to enroll dependents who were either ineligible or became ineligible. Specifically, the court noted that the employer’s administrative procedures focused too much on reducing expenses while overlooking how simple screening for age would be.

Ultimately, the court concluded that although the plan document required the employee to notify the insurer of changes in dependents’ eligibility status, the employee’s failure did not relieve the employer and insurer of their fiduciary duties. Therefore, the court held that the appropriate remedy was a surcharge against the employer and insurer equal to the amounts the employee would have received if the coverage had been in effect when her son died.

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