Heather Cogdell v. Reliance Standard Life Insurance Company
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Opinion
USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 1 of 33
PUBLISHED
UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT
No. 24-1940
HEATHER COGDELL,
Plaintiff – Appellee,
v.
RELIANCE STANDARD LIFE INSURANCE COMPANY,
Defendant – Appellant.
No. 25-1083
Appeals from the United States District Court for the Eastern District of Virginia, at Alexandria. Anthony John Trenga, Senior District Judge. (1:23-cv-01343-AJT-JFA)
Argued: December 9, 2025 Decided: March 3, 2026
Before AGEE and QUATTLEBAUM, Circuit Judges, and FLOYD, Senior Circuit Judge. USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 2 of 33
Affirmed by published opinion. Judge Agee wrote the opinion, in which Judge Quattlebaum and Judge Floyd joined.
ARGUED: Joshua Bachrach, WILSON, ELSER, MOSKOWITZ, EDELMAN & DICKER LLP, Philadelphia, Pennsylvania, for Appellant. Benjamin W. Glass, III, BENJAMIN W. GLASS, III & ASSOCIATES, Fairfax, Virginia, for Appellee. ON BRIEF: Peter M. Moore, WILSON, ELSER, MOSKOWITZ, EDELMAN & DICKER LLP, McLean, Virginia, for Appellant. Damon R. Miller, BENJAMIN W. GLASS, III & ASSOCIATES, Fairfax, Virginia, for Appellee.
2 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 3 of 33
AGEE, Circuit Judge:
When the administrator of an employee benefits plan governed by the Employee
Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001, et seq., denies a claim for
benefits, it must employ reasonable procedures that provide the claimant with a full and
fair review of that denial. For a disability benefits claim, a plan administrator ordinarily
has 45 days to decide an internal appeal of the initial denial. But if the plan administrator
notifies the claimant that special circumstances exist and tells the claimant when a decision
is expected, it can take up to another 45 days.
If the administrator upholds the denial of benefits, ERISA allows the claimant to
seek judicial review in federal court. In undertaking that review, if the plan vests its
administrator with discretion to make eligibility determinations, and the administrator
effectively exercises that discretion, a district court must afford deference to the
administrator’s decision in most instances. However, if the administrator fails to exercise
its fiduciary discretion, then a district court may review de novo whether the claimant is
entitled to benefits.
Here, we must decide whether a plan administrator that issues an untimely decision
for an internal appeal of a disability benefits claim is entitled to deferential review. We
hold that, at least under the facts of this case, the answer is “no” given the absence of a
valid exercise of discretion.
3 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 4 of 33
I.
Heather Cogdell worked at MITRE Corporation (“MITRE”) beginning in 2014,
most recently as a Principal Business Process Engineer. In July 2021, Cogdell contracted
COVID-19 and experienced symptoms of long-COVID, including intense fatigue and
sporadic headaches, for some time after the initial illness subsided. Consequently, Cogdell
took Family and Medical Leave Act leave for the next year, during which she worked part-
time. Just as she turned a corner and started to progress, Cogdell suffered from a second
COVID-19 infection in July 2022. This second bout derailed her recovery and left her
unable to work in her job at MITRE.
Cogdell filed a claim in November 2022 for long-term disability (“LTD”) under
MITRE’s plan (the “Plan”), which was administered by Reliance. Because the Plan
required Cogdell to exhaust all other benefits before receiving LTD, she selected the day
after her short-term disability benefits ended as the “date of loss.” J.A. 224. For Cogdell to
be entitled to LTD benefits under the Plan, she must be “Totally Disabled,” meaning that,
“as a result of [a sickness] . . . during the Elimination Period[1] and for the first 24 months
for which a Monthly Benefit is payable, [she] cannot perform the material duties of [her]
regular occupation.” 2 J.A. 59.
1 The “Elimination Period” is “a period of consecutive days of Total Disability . . . for which no benefit is payable,” which “begins on the first day of Total Disability” and continues for “180 consecutive days of Total Disability.” J.A. 56, 58. 2 In a roundabout definition, the Plan provides that a “Partially Disabled” claimant is “Totally Disabled.” J.A. 59. “Partially Disabled” means that “as a result of an Injury or Sickness an Insured is capable of performing the material duties of his/her regular occupation on a part-time basis or some of the material duties on a full-time basis.” Id. 4 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 5 of 33
In a letter dated January 12, 2023, Reliance denied Cogdell’s LTD benefits claim,
concluding that she was not “Totally Disabled.” J.A. 188–91. Cogdell submitted additional
medical records to Reliance, and, in another letter dated February 17, 2023, Reliance told
her that it stood by its decision to deny benefits. J.A. 197–200.
Cogdell timely filed an internal appeal on August 15, 2023, triggering the beginning
of Reliance’s 45-day decision period. Along with a 21-page letter in support of her claim,
Cogdell submitted various documents for Reliance to consider. Records show that by
August 23, a nurse employed by Reliance had already: (a) reviewed and summarized all
the newly submitted documents; (b) “[c]onsulted other clinician with regards to this claim”;
(c) received that clinician’s concurrence in her assessment of those documents; and
(d) “suggest[ed]” the appeal be sent for a “pre-appeal” behavioral health “specialist to
determine if [Cogdell] would have a lack of function[.]” J.A. 108–09.
But Reliance did nothing more with Cogdell’s appeal until 27 days later (September
19), when it was “referred” to the internal appeals department. J.A. 116. In a September 25
letter to Cogdell, Reliance stated that it “determined [it] will require an independent
physician review” and that the letter was “to serve as notice of [its] intention to take beyond
[45] days to make a final decision.” J.A. 204–05. The September 25 letter did not include
the date Reliance expected to issue its decision, nor did it identify a “special circumstance”
to justify an extension.
On October 3, after the initial 45-day decision period lapsed, Cogdell sued Reliance
in the Eastern District of Virginia for wrongful denial of benefits under 29 U.S.C.
5 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 6 of 33
§ 1132(a)(1)(B). On October 26—72 days after Cogdell filed her appeal—Reliance upheld
its decision denying Cogdell’s claim for LTD benefits.
The parties cross-moved for judgment on the administrative record and the district
court found for Cogdell. Cogdell v. Reliance Standard Life Ins. Co., 748 F. Supp. 3d 391
(E.D. Va. 2024). At the outset, the district court rejected Reliance’s argument that it was
entitled to deferential review. See id. at 395–99. In doing so, it found that Reliance departed
from the applicable claims procedures regulations because it did not timely decide
Cogdell’s internal appeal. See id. at 399. That failure, the district court concluded, meant
that de novo review of Cogdell’s claim for benefits was appropriate. Id. The court went on
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USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 1 of 33
PUBLISHED
UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT
No. 24-1940
HEATHER COGDELL,
Plaintiff – Appellee,
v.
RELIANCE STANDARD LIFE INSURANCE COMPANY,
Defendant – Appellant.
No. 25-1083
Appeals from the United States District Court for the Eastern District of Virginia, at Alexandria. Anthony John Trenga, Senior District Judge. (1:23-cv-01343-AJT-JFA)
Argued: December 9, 2025 Decided: March 3, 2026
Before AGEE and QUATTLEBAUM, Circuit Judges, and FLOYD, Senior Circuit Judge. USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 2 of 33
Affirmed by published opinion. Judge Agee wrote the opinion, in which Judge Quattlebaum and Judge Floyd joined.
ARGUED: Joshua Bachrach, WILSON, ELSER, MOSKOWITZ, EDELMAN & DICKER LLP, Philadelphia, Pennsylvania, for Appellant. Benjamin W. Glass, III, BENJAMIN W. GLASS, III & ASSOCIATES, Fairfax, Virginia, for Appellee. ON BRIEF: Peter M. Moore, WILSON, ELSER, MOSKOWITZ, EDELMAN & DICKER LLP, McLean, Virginia, for Appellant. Damon R. Miller, BENJAMIN W. GLASS, III & ASSOCIATES, Fairfax, Virginia, for Appellee.
2 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 3 of 33
AGEE, Circuit Judge:
When the administrator of an employee benefits plan governed by the Employee
Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001, et seq., denies a claim for
benefits, it must employ reasonable procedures that provide the claimant with a full and
fair review of that denial. For a disability benefits claim, a plan administrator ordinarily
has 45 days to decide an internal appeal of the initial denial. But if the plan administrator
notifies the claimant that special circumstances exist and tells the claimant when a decision
is expected, it can take up to another 45 days.
If the administrator upholds the denial of benefits, ERISA allows the claimant to
seek judicial review in federal court. In undertaking that review, if the plan vests its
administrator with discretion to make eligibility determinations, and the administrator
effectively exercises that discretion, a district court must afford deference to the
administrator’s decision in most instances. However, if the administrator fails to exercise
its fiduciary discretion, then a district court may review de novo whether the claimant is
entitled to benefits.
Here, we must decide whether a plan administrator that issues an untimely decision
for an internal appeal of a disability benefits claim is entitled to deferential review. We
hold that, at least under the facts of this case, the answer is “no” given the absence of a
valid exercise of discretion.
3 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 4 of 33
I.
Heather Cogdell worked at MITRE Corporation (“MITRE”) beginning in 2014,
most recently as a Principal Business Process Engineer. In July 2021, Cogdell contracted
COVID-19 and experienced symptoms of long-COVID, including intense fatigue and
sporadic headaches, for some time after the initial illness subsided. Consequently, Cogdell
took Family and Medical Leave Act leave for the next year, during which she worked part-
time. Just as she turned a corner and started to progress, Cogdell suffered from a second
COVID-19 infection in July 2022. This second bout derailed her recovery and left her
unable to work in her job at MITRE.
Cogdell filed a claim in November 2022 for long-term disability (“LTD”) under
MITRE’s plan (the “Plan”), which was administered by Reliance. Because the Plan
required Cogdell to exhaust all other benefits before receiving LTD, she selected the day
after her short-term disability benefits ended as the “date of loss.” J.A. 224. For Cogdell to
be entitled to LTD benefits under the Plan, she must be “Totally Disabled,” meaning that,
“as a result of [a sickness] . . . during the Elimination Period[1] and for the first 24 months
for which a Monthly Benefit is payable, [she] cannot perform the material duties of [her]
regular occupation.” 2 J.A. 59.
1 The “Elimination Period” is “a period of consecutive days of Total Disability . . . for which no benefit is payable,” which “begins on the first day of Total Disability” and continues for “180 consecutive days of Total Disability.” J.A. 56, 58. 2 In a roundabout definition, the Plan provides that a “Partially Disabled” claimant is “Totally Disabled.” J.A. 59. “Partially Disabled” means that “as a result of an Injury or Sickness an Insured is capable of performing the material duties of his/her regular occupation on a part-time basis or some of the material duties on a full-time basis.” Id. 4 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 5 of 33
In a letter dated January 12, 2023, Reliance denied Cogdell’s LTD benefits claim,
concluding that she was not “Totally Disabled.” J.A. 188–91. Cogdell submitted additional
medical records to Reliance, and, in another letter dated February 17, 2023, Reliance told
her that it stood by its decision to deny benefits. J.A. 197–200.
Cogdell timely filed an internal appeal on August 15, 2023, triggering the beginning
of Reliance’s 45-day decision period. Along with a 21-page letter in support of her claim,
Cogdell submitted various documents for Reliance to consider. Records show that by
August 23, a nurse employed by Reliance had already: (a) reviewed and summarized all
the newly submitted documents; (b) “[c]onsulted other clinician with regards to this claim”;
(c) received that clinician’s concurrence in her assessment of those documents; and
(d) “suggest[ed]” the appeal be sent for a “pre-appeal” behavioral health “specialist to
determine if [Cogdell] would have a lack of function[.]” J.A. 108–09.
But Reliance did nothing more with Cogdell’s appeal until 27 days later (September
19), when it was “referred” to the internal appeals department. J.A. 116. In a September 25
letter to Cogdell, Reliance stated that it “determined [it] will require an independent
physician review” and that the letter was “to serve as notice of [its] intention to take beyond
[45] days to make a final decision.” J.A. 204–05. The September 25 letter did not include
the date Reliance expected to issue its decision, nor did it identify a “special circumstance”
to justify an extension.
On October 3, after the initial 45-day decision period lapsed, Cogdell sued Reliance
in the Eastern District of Virginia for wrongful denial of benefits under 29 U.S.C.
5 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 6 of 33
§ 1132(a)(1)(B). On October 26—72 days after Cogdell filed her appeal—Reliance upheld
its decision denying Cogdell’s claim for LTD benefits.
The parties cross-moved for judgment on the administrative record and the district
court found for Cogdell. Cogdell v. Reliance Standard Life Ins. Co., 748 F. Supp. 3d 391
(E.D. Va. 2024). At the outset, the district court rejected Reliance’s argument that it was
entitled to deferential review. See id. at 395–99. In doing so, it found that Reliance departed
from the applicable claims procedures regulations because it did not timely decide
Cogdell’s internal appeal. See id. at 399. That failure, the district court concluded, meant
that de novo review of Cogdell’s claim for benefits was appropriate. Id. The court went on
to make findings of fact and conclusions of law under Federal Rule of Civil Procedure 52,
and, on the merits, concluded that Cogdell was entitled to LTD benefits under the Plan. See
id. at 399–404.
After Reliance timely noticed an appeal of that decision, the district court awarded
Cogdell $210,769.49 in past-due benefits, $22,544.95 in prejudgment interest, and post-
judgment interest. J.A. 43. Reliance then timely noticed an appeal of that award, and both
appeals were consolidated for briefing and consideration. 3 We have jurisdiction under 28
U.S.C. § 1291.
3 Despite appealing both orders, Reliance challenges only the merits of the district court’s first decision, not its later calculation of the benefits owed. 6 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 7 of 33
II.
We review the district court’s “legal conclusions and application of the law to the
facts” de novo, Tatum v. RJR Pension Inv. Comm., 855 F.3d 553, 560 (4th Cir. 2017), and
its factual findings for clear error, Tekmen v. Reliance Standard Life Ins. Co., 55 F.4th 951,
964 (4th Cir. 2022).
III.
The standard of review takes center stage in this appeal. By statute, a participant in,
or beneficiary of, an ERISA-governed plan may sue in federal court “to recover benefits
due to him under the terms of his plan, to enforce his rights under the terms of the plan, or
to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. §
1132(a)(1)(B). Although ERISA is “a comprehensive and reticulated statute[,]” it does not
provide the standard of review courts are to use when deciding an action challenging
benefit eligibility determinations. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,
108–09 (1989) (quoting Nachman Corp. v. Pension Benefit Guar. Corp., 446 U.S. 359,
361 (1980)). To fill that gap, the Supreme Court has resolved that “a denial of benefits
challenged under § 1132(a)(1)(B) is to be reviewed . . . de novo [] unless the benefit plan
gives the administrator or fiduciary discretionary authority to determine eligibility for
benefits or to construe the terms of the plan.” Id. at 115. So as long as the administrator
exercises its fiduciary authority within the parameters established by the plan, ERISA, and
its regulations, a court will review its benefits determination for abuse of discretion.
7 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 8 of 33
Here we must decide two issues to apply the standard of review. The first is whether
Reliance timely decided Cogdell’s internal appeal as required by the applicable ERISA
regulations and the Plan. As we explain below, we agree with the district court that
Reliance failed to do so, meaning that Cogdell’s claim was deemed denied and that she
exhausted her administrative remedies as required to file her suit in federal court.
The second issue is whether Reliance’s failure to timely issue a decision affects the
district court’s standard of review when reviewing Cogdell’s deemed-denied claim. The
district court concluded that Reliance’s failure resulted in de novo review. We agree.
Although the Plan vests Reliance with discretion to make benefits eligibility
determinations, Reliance’s failure to timely decide Cogdell’s internal appeal amounted to
a forfeiture of fiduciary action, and no deference is due in that circumstance.
Because the district court properly reviewed Cogdell’s claim de novo, and because
Reliance does not show any legal error or clearly erroneous factfinding arising from that
review, we see no error in the court’s disability benefits determination and accordingly will
affirm the district court’s judgment.
A.
We begin with an overview of ERISA and its implementing regulations. Congress
enacted ERISA “to promote the interests of employees and their beneficiaries in employee
benefit plans, and to protect contractually defined benefits.” Firestone, 489 U.S. at 113
(cleaned up). ERISA advances these aims by “regulating the manner in which plans process
benefits claims.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 830 (2003). For
example, ERISA requires an administrator of an employee benefit plan to “provide
8 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 9 of 33
adequate notice in writing to any participant or beneficiary whose claim for benefits . . .
has been denied,” and to “afford a reasonable opportunity to any participant whose claim
for benefits has been denied for a full and fair review . . . of the decision denying the claim.”
29 U.S.C. § 1133(1)–(2).
“ERISA empowers the Secretary of Labor to ‘prescribe such regulations as he finds
necessary or appropriate to carry out’ the statutory provisions securing employee benefit
rights.” Black & Decker, 538 U.S. at 831 (quoting 29 U.S.C. § 1135). Charged with the
duty to implement ERISA’s directives, the Secretary of Labor has promulgated (and
periodically amended) claims procedure regulations. See 29 C.F.R. § 2560.503-1.
Broadly speaking, these regulations require an employee benefit plan to “establish
and maintain reasonable procedures governing the . . . appeal of adverse benefit
determinations[.]” 4 Id. § 2560.503-1(b). To be reasonable, the claims procedures for
ERISA-governed plans must comply with certain requirements relating to, for example:
the timing, manner, and content of an initial notification of a benefit determination; the
process for a claimant to administratively appeal an adverse benefits determination; and
the timing for a plan administrator to notify a claimant of its decision on appeal. Id.
§ 2560.503-1(b)(1), (f)–(i). These procedural requirements for a full and fair review “serve
two complementary purposes.” Ellis v. Metro. Life Ins. Co., 126 F.3d 228, 236 (4th Cir.
4 Relevant here, “adverse benefit determination” means “[a] denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a plan[.]” 29 C.F.R. § 2560.503-1(m)(4)(i). 9 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 10 of 33
1997). On the one hand, “[t]hey are designed to permit a plan’s administrator to resolve
disputes in an efficient, streamlined, non-adversarial manner.” Id. And on the other, they
protect claimants from “arbitrary or unprincipled decision-making.” Id.
In the late 1990s, the Secretary recognized that “speedy decisionmaking is a crucial
protection for claimants who need . . . the replacement income that disability benefits
provide[,]” ERISA; Rules and Regulations for Administration and Enforcement; Claims
Procedure, 65 Fed. Reg. 70,246, 70,247 (Nov. 21, 2000), and therefore specified certain
requirements for disability benefits plans. As for timing, a claimant for disability benefits
has 180 days to internally appeal an adverse benefits determination to the plan
administrator (sometimes referred to as an “internal appeal”). 29 C.F.R. § 2560.503-
1(h)(3)(i), (4). Once a claimant files an internal appeal, the administrator must ordinarily
issue a decision within 45 days. 5 Id. § 2560.503-1(i)(1)(i), (3)(i). That 45-day period can
be extended up to another 45 days (for a total of 90 days to decide the appeal) if the plan
administrator: (a) “determines that special circumstances . . . require an extension of time
for processing the claim”; and (b) provides the claimant, within the initial 45-day period,
with written notice that indicates (i) “the special circumstances requiring an extension of
time” and (ii) “the date by which the plan expects to render” a decision. Id.§ 2650.503-
1(i)(1)(i).
5 The clock begins when a claimant files an internal appeal regardless of “whether all the information necessary to make a benefit determination on review accompanies the filing.” 29 C.F.R. § 2560.503-1(i)(4). But if a claimant fails to submit the necessary information, the period for the administrator to issue its decision is tolled from the time it notifies the claimant of the need for additional information until the claimant responds to that request. Id. 10 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 11 of 33
Coupled with a plan administrator’s duty to provide reasonable claim resolution
procedures—such as timely deciding an internal appeal—is the claimant’s obligation to
follow and exhaust other applicable procedures before bringing an action for wrongful
denial of benefits under 29 U.S.C. § 1132. Wilson v. UnitedHealthcare Ins. Co., 27 F.4th
228, 241 (4th Cir. 2022). But what is a claimant supposed to do if the plan administrator’s
deadline passes and it has yet to issue a decision?
For about the first 25 years that ERISA was in effect, the answer was unsettled. In
the late 1990s, after concluding that “claimants should not be required to continue to pursue
claims through an administrative process that fails to meet the minimum standards of the
regulation[,]” ERISA; Rules and Regulations for Administration and Enforcement; Claims
Procedures, 63 Fed. Reg. 48,390, 48,397 (Sept. 9, 1998), the Secretary amended the
regulatory mandates and “radically overhauled” the claims regulation, Fessenden v.
Reliance Standard Life Ins. Co., 927 F.3d 998, 1002 (7th Cir. 2019) (Barrett, J.). Relevant
here, a new subsection (l) addressed a plan administrator’s “[f]ailure to establish and follow
reasonable claims procedures[,]” 29 C.F.R. § 2560.503-1(l) (2002), providing:
[I]n the case of the failure of a plan to establish or follow claims procedures consistent with the requirements of this section, a claimant shall be deemed to have exhausted the administrative remedies available under the plan and shall be entitled to pursue any available remedies under section 502(a) of the Act on the basis that the plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim.
Subsection (l) was amended again in 2016. Because “disability and lost earnings
impose severe hardship on many individuals,” Claims Procedure for Plans Providing
Disability Benefits, 81 Fed. Reg. 92,316, 92,317 (Dec. 19, 2016), the Secretary bifurcated
11 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 12 of 33
subsection (l), creating a heightened compliance standard applicable only to “[p]lans
providing disability benefits[,]” 29 C.F.R. § 2560.503-1(l)(2) (2017), and leaving that
subsection unchanged for other ERISA-governed plans, id. § 2560.503-1(l)(1). For
disability benefits claims filed on or after April 1, 2018, plan administrators must “strictly
adhere” to the claims processing regulations—such as those governing timing. Id. §
2560.503-1(l)(2)(i), (p)(3). If a plan does not do so, then, subject to a narrow de minimis
exception, “the claimant is deemed to have exhausted the administrative remedies available
under the plan,” and is “entitled to pursue any available remedies under section 502(a) of
[ERISA] on the basis that the plan has failed to provide a reasonable claims procedure that
would yield a decision on the merits of the claim.” Id. § 2560.503-1(l)(2)(i). If the claimant
opts to pursue those remedies in court, then “the claim . . . is deemed denied on review
without the exercise of discretion by an appropriate fiduciary.” Id.
B.
With that regulatory framework in mind, we first address whether Reliance timely
decided Cogdell’s internal appeal. Preliminarily, Reliance does not challenge the validity
of the timing provisions in the claims procedure regulations implementing the “full and fair
review” requirement in 29 U.S.C. § 1133(2). Oral Argument at 06:00–06:22. Those
regulations require a plan administrator to decide an internal appeal “not later than” 45
days after it is received. 29 C.F.R. § 2560.503-1(i)(1)(i), (3)(i). A plan administrator can
extend that period up to another 45 days only if it determines “special circumstances”
necessitate an extension. Id. Even then, the plan administrator must provide “written
12 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 13 of 33
notice” to the claimant that “indicate[s] th[ose] special circumstances” and the date that it
expects to issue a decision. 6 Id.
Cogdell filed her internal appeal on August 15, 2023, meaning that, absent an
extension, Reliance had 45 days (or until October 1) to issue a decision. It is undisputed
that Reliance did not issue a decision by that date. But Reliance argues that it invoked the
45-day extension—postponing its deadline to November 13—in a September 25 letter to
Cogdell. In its view, that act made its later October 26 decision timely. In the September
25 letter, Reliance stated that it intended to take beyond 45 days to decide the appeal but
did not provide the date it expected to do so. The sole explanation for the extension was
that Reliance was “await[ing] the completion” of an “independent physician review” it had
requested. J.A. 204–05. It did not say that review was a special circumstance, nor did it
explain how it could be one.
The district court rejected Reliance’s argument that it properly invoked the 45-day
extension, concluding that Reliance had only the initial 45 days to decide Cogdell’s internal
6 Following the regulation, the language of the Plan also includes the 45-day deadline, subject to a potential extension up to 45 days if special circumstances exist: We will advise the Insured of the results of our review within 45 days after we receive the Insured’s timely request for review, unless it is determined that special circumstances require an extension of time for processing the appeal. If it is determined that an extension of time for processing is required, we will give the Insured written notice of the extension prior to the termination of the initial 45-day period. In no event will such extension exceed a period of 45 days from the end of the initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the determination on review is expected to be made.
J.A. 66. 13 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 14 of 33
appeal because no special circumstances justified an extension. See Cogdell, 748 F. Supp.
at 397–99. On appeal, Reliance argues that the district court erred because, in its view, so
long as a plan administrator determines special circumstances exist, that finding in and of
itself is sufficient.
The claims regulations do not define “special circumstances,” giving little guidance
as to what it means beyond one example—“the need to hold a hearing, if the plan’s
procedures provide for a hearing.” 7 29 C.F.R. § 2560.503-1(i)(1)(i). Without further
definitional clarity, we “begin our interpretation of the regulation with its text[.]” Green v.
Brennan, 578 U.S. 547, 553 (2016). And because the text is clear, our analysis ends there
too. See id.
“Special” commonly refers to something “out of the ordinary” or “unusual.” 2
Shorter Oxford English Dictionary 2945 (5th ed. 2002). So, a circumstance is “special” in
the context of the claims regulation if it does not regularly arise in an internal appeal from
the denial of benefits. Put another way, a circumstance is not “special” if it is commonplace
in the appeals process. 8
7 A question arose at oral argument regarding the appropriate standard of review for a plan administrator’s special circumstances determination. So as long as the administrator exercises its fiduciary authority within the parameters established by the plan, ERISA, and its regulations, a court will review that determination for abuse of discretion. 8 Although “special circumstances” is plain and unambiguous, and deference to an agency’s interpretation of its own regulation is therefore not implicated, see Kisor v. Wilkie, 588 U.S. 558 (2019), we observe that our interpretation is consistent with the Secretary’s understanding of special circumstances, as articulated in the preamble to the claims regulation: (Continued) 14 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 15 of 33
Applying this framework, we hold that there were no special circumstances here.
Reliance points only to the new records Cogdell submitted with her internal appeal and the
need to have those records reviewed by “appropriate medical specialists” to ensure a “full
and fair review[.]” Opening Br. 30. But that does not explain why this event is not
“ordinary” or is in any way “unusual,” so as to be a “special circumstance.” In fact, ERISA
regulations seem to contemplate both these events as routine parts of most internal appeals.
The claims regulations not only envision that a claimant will submit more
documents and records when appealing an adverse benefit determination—they require
plans to provide claimants with the opportunity to do so as part of their reasonable claims
procedures. See 29 C.F.R. § 2560.503-1(h)(2)(ii), (4) (providing that a plan’s claims
procedures must provide a claimant with “a reasonable opportunity for a full and fair
review of a[n] . . . adverse benefit determination” and the plan must “[p]rovide [c]laimants
the opportunity to submit written comments, documents, records, and other information
In providing a limited extension opportunity for deciding group health and disability claims, it is the Department’s intention to provide plans with the flexibility necessary to handle all claims appropriately, whether such claims are easy or difficult, complete when filed or needing more information. The Department emphasizes that the time periods for decisionmaking are generally maximum periods, not automatic entitlements. If a specific claim presents no difficulty whatsoever, it may be unreasonable to delay in deciding that claim until the end of the maximum period; similarly, an extension may be imposed only for reasons beyond the control of the plan. For example, the Department would not view delays caused by cyclical or seasonal fluctuations in claims volume to be matters beyond the control of the plan that would justify an extension.
ERISA; Rules and Regulations for Administration and Enforcement; Claims Procedure, 65 Fed. Reg. at 70,250 (emphasis added). 15 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 16 of 33
relating to the claim for benefits”). And the Plan here does just that. J.A. 66 (stating that,
“[a]s part of the appeal process” Reliance will provide the claimant “with the opportunity
to send [it] written comments, documents, records, and other information related to the . .
. claim for benefits in conjunction with the . . . timely appeal”).
As for the need for an independent professional to review new records on appeal,
that is commonplace—and often required—in the internal appeal process. Further, for a
disability benefit plan’s claims procedures to be reasonable, they must provide that the plan
administrator will consult with a “health care professional” when “deciding an appeal of
any adverse benefit determination that is based in whole or in part on a medical
judgment[.]” 29 C.F.R § 2560.503-1(h)(3)(iii), (4).
Given these regulations, if new records or a physician review is a unique factor for
a particular reason, the plan administrator must explain why that is so and what makes it a
“special circumstance” in its notice to the claimant. In this case, neither the plan
administrator nor the record reveal such information. In fact, the timeline of Reliance’s
processing of Cogdell’s internal appeal confirms they were not “special circumstances.”
The record instead reveals that Reliance’s failure to complete its review within 45 days
was completely of its own making. Cogdell filed her internal appeal on August 15, 2023,
and by August 23, a nurse employed by Reliance had reviewed the newly submitted
documents, consulted another clinician about Cogdell’s claim and received that clinician’s
concurrence in her assessment, and recommended the claim be referred for an independent
evaluation. In total, it took Reliance eight days to review the new documents and records.
16 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 17 of 33
But Reliance let the file sit idle for another 27 days until it was referred to the
appeals department on September 19. An internal Reliance note from the next day reflects
that an extension was necessary “due to late appeal referral.” J.A. 116. On September 20,
Reliance finally sent a letter to Cogdell acknowledging it had received her internal appeal
and stating that it intended to take more than 45 days to issue a decision, but did not identify
a “special circumstance” justifying the delay. J.A. 202 (“Please allow this letter to serve as
notice of our intention to take beyond 45 days to make a final decision[.]”). Reliance then
sent another letter to Cogdell on September 25 stating that it was pursuing an “independent
physician review” and that it “inten[ded] to take beyond [45] days to make a final decision,
as [it] await[ed] the completion of the [physician review] and/or receipt of the []requested
information, if any such information is available for review.” 9 J.A. 204–05.
Also on September 25, Reliance referred Cogdell’s file to two independent medical
professionals, receiving the first report back only four days later, on September 29, and the
second six days after that, on October 5. J.A. 26. Reliance forwarded those reports to
Cogdell on October 11 for her to provide her input within 14 days. It then issued its final
decision upholding the denial of her claim on October 26.
9 Awaiting receipt of additional documents here is not a special circumstance sufficient to justify the 45-day extension. The regulations explicitly contain a tolling provision that provides for an extension of time “due to a claimant's failure to submit information necessary to decide a claim.” 29 C.F.R. § 2560.503-1(i)(4). This provision does not apply because Reliance did not require Cogdell to submit additional documents; it simply said she Cogdell could submit them if she wanted to. Confirming this, on September 20, a Reliance claims analyst emailed Cogdell’s counsel asking, “Do you intend to submit any additional information or shall I continue with my review.” J.A. 117. Cogdell’s counsel responded: “There is no additional information we wish to submit with the appeal.” Id. 17 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 18 of 33
Giving Reliance the benefit of the doubt, it took at most 36 days for it to decide
Cogdell’s internal appeal: (a) 6 days for its nurse to review and summarize the new
documents and records (8/17–8/23); (b) 5 days for the appeals department to review the
record and determine an independent review was necessary (9/19–9/25); (c) 10 days to
receive the independent professionals’ reports (9/25–10/5); (d) 14 days to allow Cogdell to
respond to those reports (10/11–10/25); and (e) 1 day to review those reports and issue a
final decision (10/25–10/26). This timeline, drawn from the record evidence, shows that
the new medical records Cogdell submitted with her internal appeal and the need for an
“independent physician review” were not why Reliance needed more than 45 days to issue
its decision. Reliance could have completed its review of Cogdell’s internal appeal well
within the initial 45 days. And, if it could not have, it provided no valid reason for failing
to do so.
Reliance has not shown “special circumstances” to justify an extension. Under the
plain language of the governing regulations, the submission of new records and need for
independent physician review are contemplated in most, and available to all, as part of the
internal appeals process. By definition, these are not “special circumstances,” absent
something more. And nothing “more” appears on this record that would tip the balance
from the ordinary review of an internal appeal to “special circumstances” permitting
18 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 19 of 33
Reliance to invoke an extension. This recognition is fatal to Reliance’s argument that it
was entitled to another 45 days to issue a decision. 10
***
We hold that Reliance failed to invoke a 45-day extension because, on these facts,
no special circumstances justified an extension as a matter of law. Reliance thus had 45
days, or until October 1, 2023, to issue its decision. It indisputably failed to do so.
C.
We now turn to the consequences of Reliance’s failure to timely decide Cogdell’s
internal appeal. Recall that an ERISA-governed plan must “establish and maintain
reasonable procedures governing the filings of benefit claims,” and that for a plan’s claims
procedures to be reasonable, it must, among other things, adhere to the regulatory time
constraints. 29 C.F.R. § 2560.503-1(b)(1). Since the 2018 amendments took effect, a plan
administrator must “strictly adhere” to all regulatory requirements, including the timing
provision. Id. § 2560.503-1(l)(2)(i). At the outset, we have no trouble concluding that
Reliance did not strictly adhere to the regulations because, as discussed above, it did not
timely decide Cogdell’s internal appeal.
10 The regulations reflect that determining “special circumstances” is not the sole requirement for a 45-day extension, as the administrator “shall” provide written notice to the claimant that “indicate[s] the special circumstances requiring an extension of time and the date by which the plan expects to render the determination on review.” 29 C.F.R. § 2560.503-1(i)(1)(i) (emphasis added). Reliance never gave Cogdell “the date by which the plan expect[ed] to render [its] determination[.]” Id. Arguably, this defect could independently negate Reliance’s argument that it properly invoked an extension. However, the district court did not rely on this point. Since we resolve this case on the “special circumstances” issue, we leave the date-certain requirement for resolution in another case on another day. 19 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 20 of 33
In light of that failure, the claims processing regulations provide two consequences.
First, unless a narrow de minimis exception applies, “the claimant is deemed to have
exhausted the administrative remedies available under the plan . . . [and] is entitled to
pursue any available remedies under [29 U.S.C. § 1132].” Id. Second, if the claimant opts
to pursue those remedies, then “the claim or appeal is deemed denied on review without
the exercise of discretion by an appropriate fiduciary.” Id.
On appeal, Reliance agrees that an untimely decision permits Cogdell to file a
lawsuit without exhausting her administrative remedies but argues that it does not affect
the applicable standard of review. We certainly agree with Reliance that, because the de
minimis exception does not apply here, 11 Cogdell’s administrative remedies were
exhausted on October 1, 2023, and that she timely sought review of her entitlement to
benefits in federal court.
However, we disagree with Reliance’s argument as to the standard of review on the
merits. For the reasons explained below, we hold that there was no exercise of discretion
by Reliance as the plan administrator to which deference would be owed. Therefore, the
district court was correct to review Cogdell’s claim de novo.
11 The de minimis exception provides that a claimant does not exhaust administrative remedies due to a plan’s failure to strictly adhere to the claims processing regulation if the regulatory violation was (i) de minimis; (ii) non-prejudicial; (iii) attributable to good cause or matters beyond the administrator’s control; (iv) in the context of an ongoing good-faith exchange of information between the administrator and the claimant; and (v) not reflective of a pattern or practice of noncompliance. § 2560.503-1(l)(2)(ii). Although Reliance argues that its late decision did not prejudice Cogdell, it never explains how it was de minimis. And even if the violation was de minimis, the fact that Reliance alone was responsible for its inability to issue a timely decision means that the violation cannot be attributable to good cause or matters beyond its control. 20 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 21 of 33
1.
Congress “left to the courts the development of review standards” in the ERISA
context. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 116 (2008). When discerning the
appropriate standard of review, the Supreme Court in Firestone observed that because
“ERISA abounds with the language and terminology of trust law,” “principles of trust law”
must guide courts in that task. 489 U.S. at 110–11. In other words, Firestone “was
essentially an application of the common law of trusts to judicial review of ERISA claim
denials.” Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 632 (10th Cir. 2003).
Those trust principles “make a deferential standard of review appropriate when a
trustee exercises discretionary powers.” Firestone, 489 U.S. at 111 (citing Restatement
(Second) of Trusts § 187 (1959)). “[W]hen trustees are in existence, and capable of acting,
a court of equity will not interfere to control them in the exercise of a discretion vested in
them by the instrument under which they act.” Id. (quoting Nichols v. Eaton, 91 U.S. 716,
724–25 (1875) (emphasis added)); see also Restatement (Second) of Trusts § 287 (2007)
(“[W]hen a trustee has discretion with respect to the exercise of a power, its exercise [i]s
subject to supervision by a court only to prevent abuse of discretion.”).
Firestone applied these trust law principles to make clear that review for abuse of
discretion is appropriate only when (1) the plan confers discretionary authority to the
administrator to “determine eligibility for benefits or to construe the terms of the plan”;
and (2) the administrator actually exercises that discretionary authority. Firestone, 489
U.S. at 115; see also Fessenden, 927 F.3d at 1001 (“[The abuse of discretion] standard
reflects deference to the administrator’s exercise of discretion.” (emphasis added));
21 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 22 of 33
Nichols v. Prudential Ins. Co. of Am., 406 F.3d 98, 109 (2d Cir. 2005) (“[We] may give
deferential review only to actual exercises of discretion.”); Gilbertson, 328 F.3d at 631
(“[T]o be entitled to deferential review, not only must the administrator be given discretion
by the plan, but the administrator's decision in a given case must be a valid exercise of that
discretion.”). Consequently, the failure of a plan administrator to exercise its discretion in
accord with the plan, ERISA, and ERISA’s implementing regulations results in de novo
review of a benefits determination, not review for abuse of discretion.
2.
The parties agree that the Plan vests discretion in Reliance. See J.A. 64 (providing
that Reliance, as the “claims review fiduciary,” “has the discretionary authority to interpret
the [Plan and the insurance policy] and to determine eligibility for benefits”); Opening Br.
24; Resp. Br. 20–22. So the first Firestone requirement for applying a deferential standard
of review is satisfied.
That leaves the second requirement: whether Reliance as plan administrator
effectively exercised that discretion here. Had Reliance never issued a final decision
disposing of Cogdell’s internal appeal, the answer would clearly be “no” and de novo
review would apply. See Fessenden, 927 F.3d at 1001 (“[W]hen an administrator fails to
render a final decision, there is no valid exercise of discretion to which the court can defer,
and it decides de novo whether the insured is entitled to benefits.”); Gritzer v. CBS, Inc.,
275 F.3d 291, 296 (3d Cir. 2002) (“Where a trustee fails to act or to exercise his or her
discretion, de novo review is appropriate because the trustee has forfeited the privilege to
apply his or her discretion; it is the trustee’s analysis, not his or her right to use discretion
22 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 23 of 33
or a mere arbitrary denial, to which a court should defer.”); Trs. of Cent. States, Se. & Sw.
Areas Health & Welfare Fund v. State Farm Mut. Auto. Ins. Co., 17 F.3d 1081, 1083 (7th
Cir. 1994) (“Deferential review is appropriate only when the trust instrument allows the
trustee to interpret the instrument and when the trustee has in fact interpreted the
instrument.” (emphasis added)). And Reliance agrees. Opening Br. 33.
Reliance contends that it did issue a final decision upholding its denial of Cogdell’s
claim on October 26—even though that was more than three weeks after the 45-day
deadline. Reliance argues that the October 26 decision was nonetheless a valid exercise of
discretion for two reasons, and that the district court should have afforded it deference. We
disagree.
First, Reliance argues that its late decision makes this case different from those that
have held that a plan administrator forfeits discretionary review when it simply fails to
decide an internal appeal. This is in essence a substantial compliance argument—Reliance
ultimately issued a decision, it was just 25 days late. No harm, no foul? We think not.
It’s true that, as Reliance points out, we have held that “substantial compliance with
the spirit of the regulation will suffice, for not all procedural defects will invalidate a plan
administrator’s decision.” Ellis, 126 F.3d at 235 (cleaned up). “Substantial compliance
exists where the claimant is provided with ‘a statement of reasons that, under the
circumstances of the case, permitted a sufficiently clear understanding of the
administrator’s position to permit effective review.’” Id. (quoting Brogan v. Holland, 105
F.3d 158, 165 (4th Cir. 1997)). But we have not located, and Reliance has not cited, a single
23 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 24 of 33
case where we have applied the substantial compliance doctrine to the failure to observe
the affirmative requirements of ERISA’s timing regulations or the provisions of the Plan.
To the extent Reliance asks us to do so here, we decline.
Firestone provides that we apply the trust law principle that “a court of equity will
not interfere to control [trustees] in the exercise of a discretion vested in them by the
instrument under which they act.” Firestone, 489 U.S. at 111 (cleaned up). But the ERISA
regulations impose enforceable requirements on ERISA plans, and the Plan places
temporal limits on Reliance’s ability as plan administrator to exercise its discretion.
Consequently, the failure to follow the Plan’s time restraints negates the discretion that
would otherwise be due. All that’s to say, both the ERISA regulation and the Plan required
Reliance to decide Cogdell’s internal appeal within 45 days. Because “[d]ecisions made
outside the boundaries of conferred discretion are not exercises of discretion,” Jebian v.
Hewlett Packard Co. Emp. Benefits Org. Income Prot. Plan, 349 F.3d 1098, 1104 (9th Cir.
2003), Reliance’s failure to issue a decision within the 45 days meant it failed to exercise
its fiduciary discretion. A late decision, absent unusual circumstances not present here, is
not entitled to deference because Reliance lacks the authority to take longer than the
regulations and the Plan permit. 12 See Fessenden, 927 F.3d at 1004.
12 Reliance argues that Fessenden is inapposite because here Reliance decided Cogdell’s internal appeal within 90 days of receiving Cogdell’s request for review, while the decision in Fessenden was issued after the 90-day window closed. This is a distinction without a difference for present purposes because Reliance was only entitled to 45 days to begin with. When operating within a fiduciary world in which an administrator has only 45 days in which to act, its decision on day 72 is just as untimely as one on day 92. Neither are valid exercises of fiduciary discretion. 24 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 25 of 33
A plan administrator’s compliance with rules conditioning the exercise of its
discretion is fundamentally different from an administrator’s compliance with rules about
its substantive exercise of that discretion. As to the former, compliance either exists or it
does not—those form the boundaries within which it can exercise its discretion. As to the
latter, it has leeway to exercise discretion within those boundaries.
This case illustrates that distinction. Along with her request for an internal appeal,
Cogdell submitted new records and documents to Reliance to support her claim. Once
Reliance failed to timely issue its decision, Cogdell’s claim was deemed denied and she
was entitled to seek judicial review. See id. § 2560.503-1(l)(2)(i). At that point, however,
Cogdell had no explanation from Reliance about how it reviewed her claim on appeal.
Thus, she could not “prepare an appeal for further administrative review or recourse to the
federal courts.” Ellis, 126 F.3d at 237. And when Cogdell sued, still with no decision, the
district court could not “perform the task, entrusted to [it] by ERISA, of reviewing a claim
denial[,]” id., because there was nothing to review. Instead, “[t]he district court was
presented with a claim for benefits based on evidence that, for all [Cogdell] and the court
knew, Reliance had not yet considered, and had certainly not accounted for in any decision
on [Cogdell]’s claim.” 13 Fessenden, 927 F.3d at 1005.
13 A fortiori, we reject Reliance’s argument that it exercised its discretion when it denied Cogdell’s claim initially (before the internal appeal) and that the district court should have afforded that decision deference. Opening Br. 39. To do so would essentially negate the internal appeal process. After all, “[t]he purpose of the ERISA mandated appeal process is an important one. That process enables a claimant who is denied benefits to have an impartial administrative review, but also make an administrative record for a court review if that later occurs.” Gagliano v. Reliance Standard Life Ins. Co., 547 F.3d 230, 235 (4th Cir. 2008). The initial decision is therefore of no relevance here. 25 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 26 of 33
As then-Judge Barrett explained in Fessenden:
Reliance’s position that an administrator can change the standard of review with a late-breaking decision would therefore be a novel application of the substantial compliance doctrine. And permitting that novelty would undercut the benefits of exhaustion for claimants. A claimant is entitled to sue as soon as a claim is deemed exhausted because the administrator has failed to make a timely decision. But Reliance’s position would leave such a claimant in an uncertain position. Should she wait a little bit longer just in case the administrator makes a decision? Or should she go ahead, attempting to frame her case in a way that is responsive to a decision that hasn't yet—but may still—come?
Id. Like the Seventh Circuit, we conclude that the substantial compliance doctrine is
incompatible with the applicable ERISA time restraints. 14 Id. at 1004–05.
14 Accordingly, many cases Reliance cites are unpersuasive. For example, Reliance urges us to adopt the Eighth Circuit’s holding in McIntyre v. Reliance Standard Life Insurance Co., 73 F.4th 993, 999 (8th Cir. 2023), that a “procedural irregularity” does not strip a plan administrator of its discretionary authority, but is “one of many factors” to consider when determining whether an administrator abused its discretion. Of critical distinction, the claim in McIntyre was filed before January 1, 2021, id. at 998, and therefore was not subject to the amended subsection (l) which now requires strict adherence. To the extent this rule still applies in the Eighth Circuit, it is inconsistent with our conclusion above that one cannot substantially comply with a regulatory time deadline in most circumstances. The Ninth Circuit’s holding in Jebian—that “inconsequential violations of the deadlines would not entitle the claimant to de novo review, in the context of an ongoing, good faith exchange of information between the administrator and the claimant[,]” 349 F.3d at 1107 (cleaned up)—is unpersuasive for the same reason. The same goes for the Fifth Circuit’s decision in Southern Farm Bureau Life Insurance Co. v. Moore, which merely stated with no discussion or explanation that “the standard of review is no different whether the claim is actually denied or is deemed denied.” 993 F.2d 98, 101 (5th Cir. 1993). Having resolved the timeliness issue, we need not address today whether the substantial compliance doctrine could still apply in other circumstances. 26 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 27 of 33
Reliance next invokes the Supreme Court’s recent decision in Loper Bright
Enterprises v. Raimondo, 603 U.S. 369 (2024), 15 to argue that the 2018 amendment to
subsection (l) was an impermissible exercise of the Secretary’s rulemaking authority. In
particular, it challenges 29 C.F.R. § 2560.503-1(l)(2)(i), which provides that if a claimant
opts to seek review of an entitlement to benefits in federal court, the claim is “deemed
denied on review without the exercise of discretion by an appropriate fiduciary.” 16
According to Reliance, even though ERISA does not grant the Secretary the authority to
do so, that provision “sets forth the judicial consequences of a fiduciary’s failure to follow
the procedures by specifically revoking discretion.” Opening Br. 33 (emphasis in original).
We find no merit in this argument.
Reliance appears to argue that its untimely decision would otherwise be entitled to
deferential review but for that one provision in subsection (l). As demonstrated by our
lengthy discussion above, however, our holding as to the applicable standard of review—
that de novo review is necessary because Reliance did not timely decide Cogdell’s internal
appeal—is not mandated by subsection (l)(2)(i), but by Firestone and the principles of trust
law we must consider when determining the appropriate standard of review. Firestone, 489
U.S. at 110–11. Subsection (l) simply says that a certain set of circumstances leads to a
15 In Loper Bright, the Supreme Court held that courts may not defer to an agency’s interpretation of a statute simply because a statute is ambiguous. 603 U.S. at 413. 16 As far as we can tell, Reliance does not challenge other portions of subsection (l), such as those requiring strict adherence to the claims processing regulations and addressing when a claimant exhausts administrative remedies. 27 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 28 of 33
certain result. It does not, however, invade the role of courts in setting the standard of
review. 17 We need not decide whether the Secretary exceeded the broad express delegation
of authority to promulgate regulations by dictating standards of review because subsection
(l) does not do so. Loper Bright is simply inapplicable here. 18
17 The Department of Labor recognized as much when promulgating subsection (l): The Department does not intend to establish a general rule regarding the level of deference that a reviewing court may choose to give a fiduciary’s decision interpreting benefit provisions in the plan’s governing documents. However, the cases reviewing a plan fiduciary’s decision under a deferential arbitrary or capricious standard are based on the idea that the plan documents give the fiduciary discretionary authority to interpret the plan documents. By providing that the claim is deemed denied without the exercise of fiduciary discretion, the regulation relies on the regulatory authority granted the Department in ERISA sections 503 and 505 and is intended to define what constitutes a denial of a claim. The legal effect of the definition may be that a court would conclude that de novo review is appropriate because of the regulation that determines as a matter of law that no fiduciary discretion was exercised in denying the claim. Claims Procedure for Plans Providing Disability Benefits, 81 Fed. Reg. at 92,327–28 (emphasis added). 18 Loper Bright is all the more not in play here since ERISA’s grant of authority to the Secretary is exceptionally broad: “ERISA empowers the Secretary of Labor to ‘prescribe such regulations as he finds necessary or appropriate to carry out’ the statutory provisions securing employee benefit rights.” Black & Decker, 538 U.S. at 831 (quoting 29 U.S.C. § 1135); see 29 U.S.C. § 1133(2) (requiring an employee benefit plan to, “[i]n accordance with regulations of the Secretary . . . afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim” (emphasis added)); see also Midthun-Hensen ex rel. K.H. v. Grp. Health Coop. of S. Cent. Wisc., Inc., 110 F.4th 984, 988 (7th Cir. 2024) (“ERISA authorizes rulemaking, see 29 U.S.C. § 1135, and we need not address how Loper Bright . . . applies to regulations adopted under an express delegation.”). Likewise, we see no ambiguity in those express and plain grants of authority which do not implicate the very basis of Loper Bright: that courts cannot defer to an agency’s interpretation of an ambiguous statute. See 603 U.S. at 413. 28 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 29 of 33
A court will review a plan administrator’s decision regarding a claimant’s
entitlement to benefits for abuse of discretion only if the plan confers discretion to the
administrator and the administrator exercises that discretion in accordance with the plan,
ERISA and its regulations. ERISA’s regulations define the extent to which an administrator
can exercise that authority, meaning that an administrator cannot exercise its discretion
when it fails to meet regulatory deadlines. Without an exercise of discretion, there is no
discretionary act to which deference is owed, and a federal court in that circumstance
should review de novo whether a claimant is entitled to benefits.
The terms of the Plan and the claims regulation provide that Reliance had 45 days
to decide Cogdell’s internal appeal. Those 45 days came and went with no decision from
Reliance. There was no exercise of discretion, much less a discretionary act to which the
district court could defer. Thus, the district court correctly reviewed de novo whether
Cogdell was entitled to benefits under the Plan.
D.
With the threshold arguments relating to the district court’s standard of review now
resolved, we turn to the merits of Cogdell’s claim. We review a district court’s decision
following a de novo review of a claimant’s entitlement to benefits under a mixed standard
of review—factual findings for clear error and conclusions of law de novo. Tekmen, 55
F.4th at 964. The district court concluded that Cogdell was entitled to benefits under the
Plan. Finding no error in either the district court’s findings of facts or legal conclusions,
we reject Reliance’s contrary arguments and affirm the award of benefits to Cogdell.
29 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 30 of 33
Reliance first argues that the district court erroneously evaluated Cogdell’s claim
based on her specific job at MITRE rather than the duties of her “regular occupation.”
Opening Br. 43. We disagree. To be entitled to benefits, the Plan requires Cogdell to have
been “Totally Disabled,” meaning that “as a result of [a sickness for a specified period she]
cannot perform the material duties of []her regular occupation.” J.A. 59 (emphasis added).
The Plan, however, does not define “regular occupation.” In that event, the “applicable
definition . . . shall be a position of the same general character of the insured’s previous
job, requiring similar skills and training, and involving comparable duties.” Gallagher v.
Reliance Standard Life Ins. Co., 305 F.3d 264, 270–71 (4th Cir. 2002) (quoting Kinstler v.
First Reliance Standard Ins. Co., 181 F.3d 243, 252 (2d. Cir. 1999)).
The district court relied on a job description in the administrative record for a
“Business Process Engineer, Principal” position at MITRE from May 2023 to establish the
“material duties” of Cogdell’s regular occupation. Cogdell, 748 F. Supp. 3d at 399–400.
According to Reliance, this was error because the job description says nothing about the
physical or cognitive requirements. It further argues that because some of the medical
records show that Cogdell can physically perform “light work,” the district court should
have more broadly considered whether Cogdell could essentially perform “all the material
duties of her regular occupation”—which Reliance argues is a “sedentary role.” Reliance
also cites its internal vocational rehabilitation specialist’s reliance on the Dictionary of
Occupational Titles (“DOT”) entry for “consultant,” which lists generic and broad tasks,
i.e., “conducts study or survey on need or problem to obtain data required for solution.”
Opening Br. 46 (citing J.A. 384–86).
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As the fact finder, and owing no deference to Reliance, the district court reasonably
identified Cogdell’s occupation and its associated duties. The court was entitled to credit
the job description (posted to backfill Cogdell’s position) and other evidence in the record
(such as Cogdell’s resume and statements) to ascertain those “material duties.” Gallagher,
305 F.3d at 270–71; Tekmen, 55 F.4th at 961 (describing de novo review). Nor did the
court clearly err in not crediting the DOT entry for “Consultant” as many of the broad tasks
it listed do not “involve comparable duties” to the work Cogdell performed in her role at
MITRE. See Gallagher, 305 F.3d at 272 (“A general job description of the DOT, to be
applicable, must involve comparable duties but not necessarily every duty.”). Lastly,
Reliance’s argument that a sedentary task finding compels a denial of benefits relies on a
fallacy: “sedentary occupations require a certain physical capacity, you are capable of
meeting those physical requirements, your regular occupation is sedentary, therefore you
can perform your occupation.” Ward v. Reliance Standard Life Ins. Co., No. 23-2147, 2024
WL 3206709, at *7 (D. Md. June 21, 2024). This reasoning leaves out any consideration
of the cognitive requirements of Cogdell’s occupation, which the record shows the district
court sufficiently (and correctly) considered. At bottom, there is sufficient evidence to
support the district court’s assessment of Cogdell’s “regular occupation.”
Reliance next argues that the district court erred by not considering the reports from
the two independent medical professionals that Reliance received after Cogdell’s claim
was deemed denied and she filed suit. When, as here, a district court reviews a claimant’s
entitlement to benefits de novo, we have instructed that it “should review only the
evidentiary record that was presented to the plan administrator” unless it determines “that
31 USCA4 Appeal: 24-1940 Doc: 42 Filed: 03/03/2026 Pg: 32 of 33
additional evidence is necessary for resolution of the benefit claim.” Quesinberry v. Life
Ins. Co. of N. Am., 987 F.2d 1017, 1026–27 (4th Cir. 1993). We again disagree with
Reliance.
The district court expressly recognized the applicable standard and declined to
exercise its discretion to consider additional evidence when it noted that, “absent
exceptional circumstances,” it was to look “only to the evidence in the administrative
record presented by the claimant at the time the claim was administratively exhausted.”
Cogdell, 748 F. Supp. 3d at 404. We see no abuse of discretion in the district court’s
decision not to consider evidence that the claims processing regulations required be
provided to Cogdell with an opportunity to respond within the appeals period because the
evidence was not provided until after the claim was deemed denied, leaving Cogdell with
no opportunity to respond. See 29 C.F.R. § 2560.503-1(h)(4)(i). Had Reliance processed
Cogdell’s internal appeal in a timely manner, those reports could have been part of the
administrative record. But as discussed above, it did not and the district court did not err
by not considering them.
Last, Reliance argues that the district court impermissibly applied a “treating
physician” rule, assigning more weight to certain reports from Cogdell’s treating
physicians. But “district courts are institutionally assigned the role of finder of fact” and
that role encompasses “assessing credibility and determining the appropriate weight to
assign evidence.” Tekmen, 55 F.4th at 961. We held in Tekmen that when “the district court
determines that the accounts of treating physicians are more persuasive than those of
physicians who only examined a paper record, it is not error for the district court to assign
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those opinions more weight.” Id. at 966. Although Reliance may dispute the weight of the
evidence, given the district court’s extensive review of the record evidence that supports
its conclusion that Cogdell was “Totally Disabled,” Reliance has failed to show anything
that would leave this Court “with the definite and firm conviction that a mistake has been
committed.” Id. at 964.
Having otherwise reviewed the district court’s merits determination and seeing no
error, we reject Reliance’s remaining arguments, see, e.g., Reply Br. 20–24, and will affirm
the district court’s decision.
IV.
For the reasons discussed above, the judgment of the district court is
AFFIRMED.
Related
Cite This Page — Counsel Stack
Heather Cogdell v. Reliance Standard Life Insurance Company, Counsel Stack Legal Research, https://law.counselstack.com/opinion/heather-cogdell-v-reliance-standard-life-insurance-company-ca4-2026.