J.H. v. Anthem Blue Cross Life and Health Insurance Co.
No. 24-4052. 5/21/2025. D.Utah. Judge Hartz. Employee Retirement Income Security Act—Employee Welfare Benefit Plan—Limitations Period—Time-Barred Actions.
May 21, 2025
J.H. had an employee welfare benefit plan (the plan) insured through Anthem Blue Cross Life and Health Insurance Company (Anthem). The plan provides coverage for medically necessary treatment of mental health conditions and substance abuse. J.H.’s son, A.H., entered a residential treatment center in May 2020 and became covered under Anthem on July 1, 2020. A.H. received care at the treatment center until June 2021. On July 9, 2020, Anthem determined that A.H.’s residential treatment was not medically necessary, and it denied coverage. A year later, J.H. and A.H. (plaintiffs) submitted an internal appeal, and in August 2021 Anthem affirmed the coverage denial. Plaintiffs then requested external review by the California Department of Insurance, which affirmed Anthem’s decision in October 2021. Plaintiffs then sued Anthem for recovery of benefits under Employee Retirement Income Security Act (ERISA) § 502(a)(1)(B), 29 USC § 1132(a)(1)(B), which allows a plan participant or beneficiary to bring a civil action to recover benefits or to enforce rights under the plan terms. The district court dismissed the action as time-barred under the plan’s one-year limitations period for § 502(a) actions.
On appeal, plaintiffs argued that the plan’s three-year limitations period and its one-year limitations provision are ambiguous about which limitations period applies, so they are entitled to the three-year period because ambiguities must be construed in their favor. ERISA does not include a statute of limitations for filing a lawsuit under § 502(a)(1)(B), so ERISA-governed plans often specify a limitations period. Here, the plan’s “Legal Actions” section states that no action “may be started later than three years from the time written proof of loss is required to be furnished. If you bring a civil action under Section 502(a) of ERISA, you must bring it within one year of the grievance or appeal decision.” The Tenth Circuit concluded that the three-year provision warns insureds to file suit within three years of when the proof of loss had to be furnished to Anthem, while the one-year provision adds another deadline, warning insureds to file suit within a year of the grievance or appeal decision. There is thus no conflict between the provisions because the deadlines are triggered by different events. Accordingly, if an insured files suit after either deadline, the claim is barred. Plaintiffs’ one-year limitations period began in October 2021 when the final appeal was decided, but they filed their 502(a) action a year and nine months later. Therefore, their action was time-barred.
The dismissal was affirmed.