Deadlines inside an ERISA disability appeal can affect more than when a decision arrives. In Klusmann v. AT&T Umbrella Benefit Plan No. 1, an Ohio federal court applied de novo review after the claim administrator issued its appeal decision two days after the extended deadline. The court then awarded long-term disability benefits based on a complete administrative record.
The claimant had worked in a heavy physical job maintaining outside telephone facilities. After a bicycle accident, he experienced a traumatic brain injury, multiple elbow surgeries, seizures, cognitive and emotional symptoms, and physical limitations. Sedgwick paid short-term disability benefits but denied long-term benefits under a definition that required him to be unable to perform any qualifying occupation.
Why a two-day delay mattered
The claimant appealed on April 30, 2024. Sedgwick took a permitted extension and set July 29 as its decision deadline, but issued the decision on July 31. The court held that the disability-claim regulations required de novo review because the decision was late and the regulatory exception did not apply.
The court treated the two-day violation as minor in length. Even so, Sedgwick did not show good cause or circumstances beyond the plan’s control. The delay in scheduling an independent examination was attributed to Sedgwick, and it had received the examination and vocational analysis well before the deadline. This was a fact-specific application of a multi-part regulatory rule, not a holding that every brief delay automatically changes the standard of review.
Objective evidence addressed both body and brain
The appeal included a functional capacity evaluation that documented physical limits and a neuropsychological evaluation that used multiple cognitive tests. The court found both qualified as objective medical information under the plan. The administrator’s independent examiner concluded that the claimant could perform simple, supervised sedentary work, but did not meaningfully address or refute the functional and neuropsychological reports.
Looking at the record fresh, the court found that the evidence established disability under the plan’s any-occupation standard. It awarded benefits retroactive to November 15, 2023. The court declined to remand because the record was complete and the administrator had already received the evidence it failed to answer.
Practical lessons for an administrative appeal
Claimants and counsel can preserve decision letters, extension notices, submission dates, and proof of delivery so the appeal timeline can be reconstructed accurately. When disability involves several conditions, the record should also connect test results to sustained work functions. Functional testing and neuropsychological evidence may be especially useful when an insurer focuses on a narrower set of restrictions or proposed alternative jobs.
Klusmann is a nonprecedential district-court decision based on its plan language, timing record, and medical proof. Other courts may interpret the regulations differently, and different evidence may support remand or denial rather than a benefits award.
Feden Law Group can help assess an ERISA disability denial, administrative appeal, or federal court issue. Learn about our disability practice or schedule an initial consultation.
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