Santana-Diaz v. Metropolitan Life Insurance Co , 919 F.3d 691 ( 2019 )

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
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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."
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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
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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
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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.
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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
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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.
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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
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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
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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.
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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
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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
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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
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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
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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.
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