Santana-Diaz v. Metropolitan Life Insurance Co ( 2019 )


Menu:
  •           United States Court of Appeals
    For the First Circuit
    No. 17-1428
    DIONISIO SANTANA-DÍAZ,
    Plaintiff, Appellant,
    v.
    METROPOLITAN LIFE INSURANCE COMPANY,
    Defendant, Appellee,
    SHELL CHEMICAL YABUCOA, INC.; BUCKEYE CARIBBEAN TERMINAL, LLC,
    f/k/a Shell Chemical Yabucoa, Inc.; IKON GROUP, INC.; JOHN DOE;
    JANE DOE; XYZ ADMINISTRATOR, INC.,
    Defendants.
    APPEAL FROM THE UNITED STATES DISTRICT COURT
    FOR THE DISTRICT OF PUERTO RICO
    [Hon. Aida M. Delgado-Colón, U.S. District Judge]
    Before
    Howard, Chief Judge,
    Thompson and Barron, Circuit Judges.
    Efraín Maceira-Ortiz for appellant.
    Frank Gotay-Barquet, with whom Gotay & Pérez, P.S.C. was on
    brief, for appellee.
    March 29, 2019
    HOWARD, Chief Judge.       This case concerns the denial of
    long-term    disability    ("LTD")    benefits    for       Plaintiff-Appellant
    Dionisio    Santana-Díaz    ("Santana")      under    his     employee    welfare
    benefit plan ("Plan").      After the Plan's administrator, Defendant-
    Appellee    Metropolitan    Life   Insurance     Co.    ("MetLife"),      denied
    Santana's LTD benefits claim, Santana brought suit under the
    Employee    Retirement    Income   Security     Act    of    1974,   as   amended
    ("ERISA"), 29 U.S.C. §§ 1001-1461.           Applying the parties' agreed-
    upon standard of review, the district court granted judgment on
    the administrative record to MetLife.            For the reasons discussed
    below, we AFFIRM.
    I.
    We begin with the basic facts leading to August 2011,
    when MetLife denied Santana's claim for LTD benefits under the
    Plan through his employer, Shell Chemical Yabucoa, Inc.                    Shell
    Chemical employed Santana as an accountant for over 25 years.
    Santana submitted a disability claim form for disabilities that
    arose in late 2007.        MetLife approved the claim, which was for
    disabilities arising from a mental disorder or illness due to major
    depression. MetLife paid Santana benefits under the Plan's limited
    24-month benefit duration period, effective as of November 2008.
    Over the course of 2010 and 2011, Santana and MetLife
    exchanged a series of correspondence.                MetLife sent Santana a
    letter in April 2010 informing him that his limited disability
    - 2 -
    benefits   would    expire      that      November   unless       MetLife   received
    objective medical information establishing that he was eligible
    for LTD benefits.        In November 2010, MetLife sent Santana another
    letter, this time terminating his disability benefits on the ground
    that his disability was a limited-benefit condition.1                         MetLife
    further    explained     that    "based      on   review     of   the     information
    submitted for [Santana's] non psychiatric medical issues, the
    medical documentation does not support the inability for [Santana]
    to perform [his] job which is sedentary in nature or any exclusion
    to the 24 month limitation."              The letter also advised Santana of
    his right to appeal the denial of benefits with MetLife, which he
    proceeded to do in April 2011.              Santana explained in his appeal
    that the combination of mental and physical conditions rendered
    him completely disabled from any employment.
    In its review of Santana's appeal, MetLife consulted two
    independent      physicians,        one     for    psychiatry       and     one    for
    occupational medicine.          That review resulted in MetLife's August
    19,   2011,     letter    denying      Santana's     claim    ("MetLife's         Final
    Decision").      MetLife's Final Decision shows that in early June
    2011, the occupational medicine consultant spoke with Santana's
    primary care physician, Dr. Catoni.                According to MetLife, "Dr.
    1The Plan excluded six physical conditions from the 24-month
    benefit limit, including, as relevant here, radiculopathies --
    defined in the Plan as "[d]isease[s] of the peripheral nerve roots
    supported by objective clinical findings of nerve pathology."
    - 3 -
    Catoni indicated to the consultant that [Santana's] main problems
    were psychological."     Dr. Catoni also told the consultant that
    Santana could not walk long distances due to diabetic neuropathy,
    and that arthritis in the shoulders limited Santana's overhead
    movement.     The consultant noted that although Dr. Catoni stated
    this, the clinical data provided did not confirm the presence of
    lumbosacral neuropathy or any diabetic peripheral neuropathy.
    Furthermore, "the consultant indicated there were no physical
    exams, office visits, or any clinical findings provided in the
    records that supported that these conditions were causing any
    physical impairment."    Consequently, the consultant concluded that
    the medical records did not support a limited benefit exclusionary
    diagnosis of radiculopathies or other enumerated conditions.
    On June 9, 2011, MetLife faxed a copy of the consultants'
    reports to Santana's doctors, requesting that they submit any
    comments on the reports.    Dr. Catoni responded, expressing concern
    about the occupational medicine consultant's report, which stated
    that there was no evidence of diabetic polyneuropathy.      He noted
    his office record from February 25, 2011, in which the condition
    was "well documented," and he accordingly sent additional records
    to MetLife.    MetLife directed the occupational medicine consultant
    to review the file further, after which the consultant stated that
    "he still had no physical examinations, objective findings or
    office visit reports that supported that the diagnosis of diabetic
    - 4 -
    peripheral neuropathy led to physical impairment and consequently
    restrictions and limitations on work abilities."
    Subsequently, MetLife's Final Decision letter denied
    Santana's claim.        In regard to Santana's doctors' diagnoses of
    diabetic polyneuropathy and other conditions, the letter explained
    that "although your physicians indicate [that] you have these
    diagnoses . . . [t]he diagnosis of a medical condition alone does
    not support an inability to function or support a disabling
    condition."     Thus, in line with its consultant's findings, MetLife
    concluded that "the medical information provided is limited and
    does    not   support   that    any   of   these     conditions      alone   or   in
    combination would preclude [Santana] from performing [his] own
    sedentary job as an accountant."
    After exhausting the Plan's administrative remedies,
    Santana began this action on August 18, 2013, filing suit under
    ERISA, 29 U.S.C. § 1132(a)(1)(B), against MetLife, and others, in
    the federal district court for Puerto Rico.                Santana claimed that
    MetLife unreasonably, arbitrarily, and capriciously denied him LTD
    benefits under the Plan.         In May 2014, MetLife moved for summary
    judgment. The district court granted summary judgment in MetLife's
    favor    in   January   2015,    holding      that   the    Plan's    statute     of
    limitations barred Santana's complaint.                 Santana appealed the
    district court's order, and, in March 2016, we reversed, holding
    that the contractual statute of limitations did not apply because
    - 5 -
    MetLife failed to advise Santana of the deadline for seeking
    judicial review of its decision.       Santana-Díaz v. Metro. Life Ins.
    Co., 
    816 F.3d 172
    (1st Cir. 2016).          In late 2016, back in the
    district   court,   the   parties   cross-moved   for    judgment   on   the
    administrative record.      In March 2017, the district court found
    that MetLife acted reasonably, and thus granted MetLife's motion.
    The district court entered final judgment the next day, and Santana
    timely appealed.
    II.
    A.
    We   review    the   district    court's     judgment    on   the
    administrative record de novo.       Buffonge v. Prudential Ins. Co. of
    Am., 
    426 F.3d 20
    , 28 (1st Cir. 2005).
    Here, we must determine whether MetLife's denial of
    Santana's LTD benefits was "arbitrary, capricious or an abuse of
    discretion."    See 
    id. To that
    end, we consider the text of the
    ERISA plan and the plain meaning of the words used therein, which
    cabin the plan's administrator's discretion.          See Colby v. Union
    Sec. Ins. Co. & Mgmt. Co. for Merrimack Anesthesia Assocs. Long
    Term Disability Plan, 
    705 F.3d 58
    , 65 (1st Cir. 2013).              In such
    plans, "the employer (or an insurance company that stands in the
    employer's shoes) must spell out exclusions distinctly."             
    Id. at 65-66.
    - 6 -
    Further, under ERISA, a disability benefits denial must
    "set[] forth the specific reasons for such denial, written in a
    manner calculated to be understood by the participant."          29 U.S.C.
    § 1133.    A plan administrator's decision "must be reasoned and
    supported by substantial evidence" -- "[i]n short, [it] must be
    reasonable."       Ortega-Candelaria v. Johnson & Johnson, 
    755 F.3d 13
    ,
    20 (1st Cir. 2014) (internal quotation marks omitted) (citing
    
    Colby, 705 F.3d at 62
    ). If the plan administrator's interpretation
    of the plan is reasonable, then it "will not be disturbed."
    Conkright v. Frommert, 
    559 U.S. 506
    , 521 (2010) (quoting Firestone
    Tire & Rubber Co. v. Bruch, 
    489 U.S. 101
    , 111 (1989)).       In deciding
    whether an interpretation of a plan is reasonable, several other
    circuits   have     advanced   various   specific   standards,   including
    looking to the consistency of an administrator's construction with
    the plain meaning of the plan or looking to several guiding
    factors.   See D&H Therapy Assocs., LLC v. Bos. Mut. Life Ins. Co.,
    
    640 F.3d 27
    , 37-38 (1st Cir. 2011) (summarizing standards in the
    Second, Third, Fourth, Fifth, Seventh, Eighth, Ninth, and D.C.
    circuits).     We consider these standards instructive but do not
    adopt them or any specific guiding factors.         
    Id. at 38.
    Santana highlights several purported deficiencies with
    the MetLife claims administrators' review and denial of his LTD
    benefits claim.        First, Santana argues that MetLife failed to
    consider     the     conditions   documented   by    Santana's    treating
    - 7 -
    physician,       Dr. Catoni,    and   his     physiatrist,2    Dr. Maldonado.
    Second, he claims that MetLife inconsistently interpreted the
    Plan, to his detriment.         Third, he argues that MetLife denied his
    claim without providing him with sufficient information regarding
    the requisite showing to qualify for LTD benefits.                   Finally,
    Santana argues that MetLife acted in an arbitrary and capricious
    manner    by    adding   a   "functional    limitations"    criterion   as    an
    additional ground for exclusion of benefits.              We address each of
    Santana's challenges in turn.
    B.
    Santana chiefly argues that the Plan Administrator's
    denial of LTD benefits to Santana was arbitrary and capricious
    because the administrator cherry-picked evidence it preferred
    while ignoring significant contrary evidence.             In support, Santana
    relies largely on the discussion in Cowern v. Prudential Insurance
    Co. of America, 
    130 F. Supp. 3d 443
    (D. Mass. 2015) (denying cross
    motions    for     summary     judgment     in    ERISA   action   challenging
    administrator's decision to terminate benefits).               In Cowern, the
    district court concluded that the administrator acted arbitrarily
    and capriciously by relying on selective comments in a doctor's
    2  Physiatrists, specialists                in physical medicine        and
    rehabilitation, treat a range of                 conditions focusing on      the
    musculoskeletal system.
    - 8 -
    report to deny the claim, ignoring other statements in the report
    that tended to support the claim.            
    Id. at 464-66.
    The Supreme Court has recognized such cherry-picking as
    a   factor    to     support     setting   aside     a    plan       administrator's
    discretionary decision.           See Metro. Life Ins. Co. v. Glenn, 
    554 U.S. 105
    , 118 (2008) (affirming the Sixth Circuit's reversal of
    the plan administrator's decision, in part because "MetLife had
    emphasized a certain medical report that favored a denial of
    benefits, had deemphasized certain other reports that suggested a
    contrary conclusion, and had failed to provide its independent
    vocational     and     medical     experts    with       all    of    the   relevant
    evidence.").       Other circuits have done the same.                See, e.g., Love
    v. Nat'l City Corp. Welfare Benefits Plan, 
    574 F.3d 392
    , 397-98
    (7th Cir. 2009) ("While plan administrators do not owe any special
    deference to the opinions of treating physicians . . . they may
    not simply ignore their medical conclusions or dismiss those
    conclusions without explanation." (internal citation omitted));
    Winkler v. Metro. Life Ins. Co., 
    170 F. App'x 167
    , 168 (2d Cir.
    2006) ("An administrator may, in exercising its discretion, weigh
    competing evidence, but it may not, as MetLife did here, cherry-
    pick the evidence it prefers while ignoring significant evidence
    to the contrary.").
    Here,    assuming     without    deciding         that    an   insurer's
    cherry-picking of favorable evidence alone may be grounds for
    - 9 -
    reversal, Santana cannot show that MetLife was guilty of that in
    processing his claim.    Santana asserts that MetLife cherry-picked
    evidence and failed to consider the conditions documented by Dr.
    Catoni and Dr. Maldonado.       Santana concludes that, contrary to
    MetLife's Final Decision, his medical records include "objective
    clinical findings" that he had a diagnosis of radiculopathies.
    This argument fails because MetLife did in fact consider the
    evidence that Santana alleges that it overlooked, but MetLife
    determined that the evidence did not satisfactorily prove that
    Santana was eligible for LTD benefits under the Plan.
    Santana first suggests that MetLife ignored two progress
    notes from Dr. Catoni, one sent to MetLife on August 5, 2010, and
    the second dated February 25, 2011, both of which included a
    diagnosis of polyneuropathy, among other conditions.           The record
    belies this contention.       As MetLife's Final Decision states,
    MetLife's consultant reviewed Dr. Catoni's progress notes and "he
    found no objective data from [those] notes to support functional
    limitations." This is the crux of the matter: Even if Dr. Catoni's
    notes   established   that   Santana   suffered   from   polyneuropathy,
    MetLife   concluded   that   the    records   "failed    to   support   any
    restrictions or limitations based on this diagnosis."
    Next, Santana draws our attention to a late-2010 record
    from Dr. Maldonado that MetLife purportedly ignored regarding an
    electromyogram ("EMG") -- but like Dr. Catoni's report, this record
    - 10 -
    is also noted in MetLife's Final Decision. Specifically, MetLife's
    Final   Decision      letter     shows    that     its    review     of    Santana's
    administrative appeal included "medical records from Dr. Maldonado
    which included EMG/NCS studies dated November 15, 2010." MetLife's
    consultant's report notes the November 2010 EMG nerve study with
    Dr. Maldonado, stating somewhat cryptically: "EMG Nerve Study;
    Peripheral    Motor     Sensory    Polyneuropathy;         Right    Femoral   Nerve
    Lesion."     MetLife's letter does not state what its consultants
    made    of   the    medical    records     that     Dr.     Maldonado      provided,
    particularly the November 2010 EMG.
    According to Santana, the November 2010 EMG study shows
    that Dr. Maldonado had diagnosed him with "Peripheral Motor Sensory
    Polyneuropathy; Right Femoral Nerve Lesion," which constitutes
    objective clinical findings of radiculopathies.                     He argues that
    this    "finding"     sustains     Dr.    Catoni's       findings     of   diabetic
    polyneuropathy in his progress notes.              But his position takes too
    much liberty with the evidence at hand.                    Despite the repeated
    references in the briefing, Santana does not actually identify the
    EMG in the record.      Rather, he points to the notation in MetLife's
    consultant's       report.     While     Santana    views    this    as    objective
    clinical     findings    of    radiculopathies,           MetLife    was    not   so
    persuaded.    It is not clear from the face of that record what the
    noted items mean, much less what they intend to show or prove.
    - 11 -
    Ironically,      Santana's        highlighting      of    Dr.     Catoni's
    statement     and    the   EMG   notation       in    the    consultant's       report
    undermines     his    argument    by     drawing      attention       to     MetLife's
    consideration of these documents.             MetLife's conclusion that these
    records failed to show that Santana was physically disabled under
    the Plan is reasonably supported by the record and thus not
    arbitrary or capricious cherry-picking.
    C.
    Next,     Santana     asserts        that       MetLife    also      acted
    arbitrarily    by    treating    medical      evidence       inconsistently.        In
    support, he cites a June 2013 letter from MetLife regarding the
    reinstatement of Santana's life insurance benefits.                        That letter
    stated that "[t]he conditions that have been considered in the
    coverage      reinstatement       were        major     depressive           disorder,
    degenerative disc disease, diabetes mellitus type 2, diabetic
    polyneuropathy, chronic pain of shoulder, high blood pressure,
    asthma and hypothyroidism."              From this statement noting that
    MetLife considered, among other things, diabetic polyneuropathy to
    reinstate life insurance benefits, Santana concludes that MetLife
    did not consistently apply and interpret the conditions to qualify
    for LTD benefits.
    This is a false equivalence.                    Contrary to Santana's
    assertion, there is no evidence that the criteria to qualify for
    life insurance benefits is the same as the criteria to qualify for
    - 12 -
    LTD benefits.         Life insurance is not included in the Plan's
    coverage for LTD benefits, further suggesting that the two involve
    separate inquiries.       Because there is no indication that MetLife
    reinstated Santana's life insurance coverage because it found him
    to be disabled due to diabetic polyneuropathy, Santana has failed
    to identify any inconsistent treatment by MetLife on the disability
    determination.    Accordingly, the comparison to his life insurance
    coverage    offers      no   basis     to     find   MetLife's    disability
    determination unreasonable.
    D.
    We turn now to the dispute over the required proof of
    Santana's disability.        The Plan states that "to receive benefits
    under This Plan, you must provide to us at your expense, and
    subject    to   our    satisfaction,"       documents   showing   proof   of
    disability.     Santana argues that MetLife failed to provide him
    with sufficient information regarding the requisite showing to
    qualify for LTD benefits.       To that end, he claims that the phrase
    "to our satisfaction" is ambiguous and is thus procedurally flawed
    because it does not provide sufficient notice to Santana of what
    constitutes satisfactory objective evidence.              Ultimately, this
    assertion rings hollow.
    A plan administrator is entitled to define ambiguous
    terms regarding proof of disability so long as its interpretation
    is reasonable.    See Pralutsky v. Metro. Life Ins. Co., 435 F.3d
    - 13 -
    833, 839 (8th Cir.), cert. denied, 
    549 U.S. 887
    (2006) (holding
    that where a plan does not define the "proof" or "documentation"
    sufficient to establish disability, it was not unreasonable for
    MetLife to interpret the plan to require objective evidence).
    MetLife told Santana that he had to submit current
    objective   medical     information      that   would   establish    that    his
    condition qualified him for LTD benefits under the Plan. MetLife's
    Final Decision also emphasized that a diagnosis of a physical
    condition does not automatically entitle Santana to benefits under
    the Plan.   In other words, MetLife required two types of objective
    evidence:   (1)    to   establish    a   qualifying     condition,    such    as
    radiculopathies, and (2) to show that the condition caused Santana
    to be disabled under the Plan.        Santana failed to do so.       MetLife's
    Final Decision explained that the evidence provided lacked any
    "physical examinations, objective findings or office visit reports
    that   supported    that    the     diagnosis     of    diabetic    peripheral
    neuropathy . . . would preclude [Santana] from performing [his]
    sedentary job as an accountant."
    Santana's attempt now to characterize the plain language
    of the claims process -- language that the Plan expressly gave
    MetLife the discretion to interpret -- as procedurally defective
    is unconvincing.        We find no abuse of discretion here because
    MetLife had the discretion to assess the sufficiency of proof
    - 14 -
    offered, and the objective evidence sought was reasonable to
    determine Santana's eligibility for LTD benefits under the Plan.
    E.
    Santana's   last   challenge    posits   that    MetLife    acted
    arbitrarily     and   capriciously    by     considering     the   functional
    limitations of his condition.        Considering functional limitations
    in connection with a physical disability claim, however, does not
    constitute an arbitrary additional criterion to allow exclusion
    from LTD benefits.       On the contrary, "[w]hen certain illnesses do
    not 'lend themselves to objective clinical findings,' the proper
    approach is to consider 'the physical limitations imposed by the
    symptoms of such illnesses [that] do lend themselves to objective
    analysis.'" Al-Abbas v. Metro. Life Ins. Co., 
    52 F. Supp. 3d 288
    ,
    297 (D. Mass. 2014) (quoting Boardman v. Prudential Ins. Co. of
    Am., 
    337 F.3d 9
    , 17 n.5 (1st Cir. 2003)).                  Furthermore, the
    discussion    of   Santana's    functional    limitations    points     to   the
    threshold question of whether he is disabled under the Plan.
    The Plan's definition of "disability" covers conditions
    that prevent an individual from making 80 percent of pre-disability
    earnings in one's occupation for any employer in the local economy.
    Functional limitations caused by an alleged physical disability
    are reasonably part and parcel of the disability assessment.
    Therefore, MetLife did not act arbitrarily by considering the
    - 15 -
    presence (or absence) of such functional limitations in assessing
    whether Santana was disabled under the Plan.
    III.
    On this record, MetLife's decision to deny LTD benefits
    to   Santana   based   on   physical    disability      was    reasonable   and
    substantially    supported     by      the   evidence     at    hand.       The
    administrative record shows a reasonably thorough claims process
    that included communications between not just MetLife and Santana,
    but also between the medical consultants and attending physicians
    involved in Santana's care and assessment.
    For   the   foregoing     reasons,   we   AFFIRM      the    district
    court's order granting judgment to MetLife.
    - 16 -