FI L ED U.S. COURT OF APPEAL S EL EVENTHCI RCUI T Oct. 21, 2009 THOMAS K. KAH

N CL ERK [DO NOT PUBLISH] IN THE UN ITED STATES COURT OF APPEALS FOR THE ELE VENTH CIRCUIT

__ __ __ __ __ __ __ __ __ __ __ __ No. 0 8- 16 78 1

__ __ __ __ __ __ __ __ __ __ __ __ D.C. Dock etNo. 0 6- 00 47 9- CV-FTM -9 9- SPC BEATRIZ MARTINEZ-CLAIB , M.D., Plai nt iff -Ap pe ll an t, ve rs us BUSINESS M EN’ S ASSURANCE COM PANY OF AMERICA, METROPOLITAN LIFE INSURANCE CORPORATION, Defen da nt s- App el le es .

__ __ __ __ __ __ __ __ __ __ __ __ App eal fro m

th e Uni te d S ta te s Di st ric t Co urt fo r th e Mi dd le Dis tri ctof F lo rid a

__ __ __ __ __ __ __ __ __ __ __ __ _ (Oct ob er 2 1, 2 00 9) Befo re EDMONDSON, BLACK an d S ILER, Cir cu itJu dg es . * SILER, Ci rcu itJu dg e:

Honora ble Eug ene E. Siler, J r., United States Circuit J udg e for the Six th Circuit, sitti ng by * designation.INT RODUCTI ON

Pl ai nt iff Bea tri z Marti ne z-Cl ai b ap pe al s fro m the dis tric t co urt’s or de r gr an ti ng su m m ary jud gm en t in f

av or of de fen da nt Met Life in th is ERISA su it . The di st ric t co urt fo un d Marti ne z-Cl ai b’s cl ai m was ti m e-b arre d, an d th at , ev en if it were ti m el y , th e pr eex is ti ng co nd it io n ex cl us io n ap pl ie d. Marti ne z-Cl ai b ap p e al s, an d fo r th e fo ll owi ng reas on s, we af

firm . I. InSep te m

be r 20 01 , Mart in ez-C la ib co nt ract edwith F am il y Heal th Care Cen te rs of S ou th wes t Fl or id a (FHC) to pro vi de ph y si ci an ’s servi ces . The co nt ract co ve reda pe rio d o f em

pl oym en t b etweenNov em be r 20 01 th ro ug h No ve m be r 20 03 an d re qu ire d F HC to pro vi de lo ng -te rm di sabi li ty ins ur an ce. Ma rti ne z-Cl ai b be ga n e m pl oym en t as a ph y si ci anwith F HC in earl y Nov em be r 20 01 . A m on th la te r, sh e su ffer eda gr an d m al bra in sei zu re. Sh e was subs eque nt ly dia gn os ed wit h abra in tu m or , andun de rwen t s ur ge ry lat er tha t m on th . She di d n otreturn t o work u nt il Feb ru ary 20 02 . In M ay , du e to he r de te rio rat in g h eal th , sh e was reas si gn edwithi n F HC to be a bi li ng ua l h eal th educ at or , a po si ti on sh e h el d u nt il Apr il 20 03 , when sh e co ul d n o l on ge r work. In Marc h 2 00 3, FHC can cel le d i ts be ne fit s p ol ic y

with M et Life , whi chwas b efo re Ma rti ne z-Cl ai b’s l as t d ay of wo rk atFHC. 2InMarc h 2 00 4, M art in ez-C la ib subm it te d h er cl ai m forlo ng -te rm

di sabi li ty be ne fit s. Th e cl ai m

was d en ie d i n aNov em

be r 20 04 let te r whi ch ex pl ai ne d t ha t he r co ve rag e d idno t b eco m e eff ect iv e u nt il Feb ru ary 20 02 (aft er the bra in se iz ur e). Itals o e xp la in edth athe r la stda y of wo rkin Apri l 2 00 3 was be y on d t he Mar ch31 da te whenFHC can cel le d i ts pl anwith M et Life . It i m pl ie d t ha t i t was co ns id eri ng he r la stda y

of wo rkas ahe al th educ at oras t he da te of d is ab il it y , and co nc lu de d t ha t co ve rag e was pre cl ud edbe cau se th atda te was o ut si de th e co ve rag e pe rio d. Al th ou gh sh e fi le d a n app eal with M et Life in May 200 5, t he ap pe al fil e was lo stan d n ev er p ro ces se d. Sh e fi le d t hi s ERI SA su itin Sep te m be r 20 06 . The pa rti es cro ss -m ot io ne d fo r su m m ary jud gm en t, an d t he di st ric t co urt gr an te d M et Life ’s m ot io n b ecau se Mart in ez-C la ib ’s cla im was t im e-b arre d. Itals o he ld , inth e al te rn at iv e, th atev enif i t wer e ti m el y , th e p reex is ti ng co nd it io n ex cl us io n app li ed . Mart in ez-C la ib ti m el y ap pe al s. II .

“ W e rev ie w th e d is tri ctco urt’s g ran t o f su m m ary jud gm en t d e n ov o, ap pl y in g t he same leg al st an da rd s as th e d is tri ctco urt.” Si erraClub, In c. v. Leav it t, 4 88 F.3d90 4, 9 11 (11 th Cir . 20 07 ). Here, the di st ric t co urt fo un d t ha t be cau se Met Life fai le d t o a cton Mart in ez-C la ib ’s app eal withi n the requi redti m e

3pe rio d, i t wo ul d d eem it s i na ct io n a n i m

pl ic itde ni al . It ap pl ie d ade no vo st an da rd of rev ie w andbo th parti es ag ree t hi s i s t he pro pe r st an da rd . Bec au se we fin d t ha t M art in ez-C la ib ’s cla im was t im e-b arre d, an d s he ha s fai le d t o m ak e a s ho win g t ha t M et Life was n otpre jud ic edby her d el ay

in fil in g he r cl ai m , we affi rm

th e d is tri ctco urt. Fi nd in g i t d et erm in at iv e o f th e cas e, we do no t re ach Mart in ez-C la ib ’s arg um en t ab ou t the pre ex is ti ng co nd it io n ex cl us io n. II I. A. As a t hr es ho ldm at te r, Marti ne z-Cl ai b c la im s t ha t M et Life m ay no t ar gu e an y rat io na le forcla im

de ni al th atitdi d n otrai se pri orto li ti ga ti on . There fo re, s he arg ue s, the co urt erredin co ns id eri ng Met Life ’s arg um en ts th atsh e fai le d t o g iv e ti m el y no ti ce o f he r cl ai m

an d t ha t the pre ex is ti ng co nd it io n e xc lu si on ap pl ie d, be cau se th e d en ia l l et te r di d n otm en ti on eit he r of th es e rea so ns forde nyin g co ve rag e. In st ead , th e le tt er re li edon fin di ng th athe r la stday of wo rkwas t he da te of d is ab il it y , andsi nc e th atda te was a fte r th e d at e FHC ca nc el le d i ts lo ng -te rm di sabi li ty pla n wi th Met Life , th ere was “ no qu al ifyin g p eri odof co ve rag e.” The di st ric t co urt al lo wedMet Life to rai se th es e arg um en ts , rel y in g o n Tip pi ttv. Re li an ce St an da rdLife I ns ur an ce Co ., whi ch reco gn iz edth atalt ho ug h a di st ric t co urt m ay

di sc ou ntor r ejectth es e ta rdy ex pl an at io ns , itwas n oterro ne ou s 4fo r a d is tri ctco urt t o c on si de r “po st -h oc expl an at io ns ab ou t wh y anin su rer d en ie d th e p la in ti ff's cla im .” 27 6 F . App ’x 91 2, 9 15 (11 th Cir . 20 08 ). It al so rel ie d o n Farl ey v. Be ne fitTrus t Li fe In su ran ce Co ., whi ch he ldth atarg um en ts th at co ve rag e d oe s n otex is t ca nn otbe waiv ed . 97 9 F .2d65 3, 6 60 (8t h C ir. 1 99 2) . The ba r to po st -h oc arg um en ts refer en cedin Tip pi ttap pl ie s o nl y incas es rev ie win g t he pl anadm in is tra to r’s de ci si onun de r th e d efer en ti al arb itrary and cap ric io us st an da rdof r ev ie w. It d oe s n otap pl y in de no vo rev ie w cas es su ch as th is . The rat io na le forth e p os t-h oc rul e is th atth e co urt ca nn otde fer t o apl an in te rp ret at io n t ha t was no t o ffer edin th e ad m in is tra ti ve pro ces s. Su ch a co nc ern is no t p res en t wh ere we a re as ke d t o re vi ew th e d en ia l o f be ne fit s d e n ov o. Be cau se th is co nt ex t d oe s n otpro vo ke ap pl ic at io n o f su ch a ru le , itcan no t o pe rat e to pr ev en t M et Life fro m

rel y in g o n re as on s fo r de nyin g M art in ez-C la ib ’s cla im th at itdi d n otori gi na ll y

in cl ud e in it s d en ia l l et te r. Marti ne z-Cl ai b a ls o a rg ue s t ha t M et Life waiv edth es e arg um en ts itdi d n ot rai se init s d en ia l l et te r. W e h av e co ns id eredwaiv er i n t he co nt ex t o f ERISA i n Glas s v . Uni te d o f Om ah a Life Ins ur an ce Co ., 33 F.3d13 41 (11 thCir . 19 94 ). In ou r di sc us si on of wai ve r, we de fin edth e te rm as “ th e v ol un ta ry , in te nt io na l rel in qu is hm en t o f a kno wn ri gh t,” a ndno te d t ha t i t i s “ a co m m on law p rin ci pl e

5who se ap pl ic ab il it y un de r ERISA i s an is su e o f fi rs t i m pr es si on in th is cir cu it .” Id . at13 47 . Giv enth atth e is su e was ne w to th e ci rcu it , we lo ok edat t wo ci rcu itco urt op in io ns to fram e th e is su e, Pi tt s b y an d Th ro ug h P it ts v. Am eri can Secu rity Life In su ran ce Co ., 93 1 F .2d35 1, 3 57 (5t h C ir. 1 99 1) ; an d Th om as on v. Aet naLife In su ran ce Co ., 9 F.3 d 6 45 , 64 8 (7 th Cir . 19 93 ), an d u lt im at el y fol lo wed Tho m as on . Tho m as on “ le ft o pe n wh ethe r wai ve r pr in ci pl es m ig htap pl y , as p artof th e fed eral co m

m on law i n t he ERISA co nt ex t, u nd er o th er ci rcu m st an ces , bu t reject edth e wai ve r arg um en t m ad e b y th e p la in ti ff i n t ha t ca se .” Glas s, 3 3 F .3dat 13 48 . W e reject edwaiv er i n t he sp eci fic co nt ex t o f th e cas e b ecau se th e cl ai m an t ha d n otsh owneit he r th atth ere was anin te nt io na l re li nqui sh m en t o f a kno wn ri gh t orth atth e in su rer was un jus tl y be ne fit te d b y

it s co nduc t. Id . Here, Me tLi fe d en ie d t he be ne fit s b ecau se itass um edMart in ez-C la ib ’s fin al da y of wo rkat F HC was th e “ da te of d is ab il it y ” an d t he refo re af te r th e p ol ic y

ha d be encan cel le d b etweenMet Life an d F HC. Thu s, i t d idno t i nt en ti on al ly giv e up th e ri gh t t o a rg ue th e o th er g ro un ds forde nyin g b en efi ts ba se d o n t he co rrec t d at e of di sabi li ty, Marti ne z-Cl ai b’s l as t d ay work in g a s a p hysic ia n. If M et Life ha d fram edhe r cl ai m

as M art in ez-C la ib subm it te d i t, u si ng th e la stda y work edas a ph y si ci anas t he da te of d is ab il it y , itco ul d n otm ak e th e arg um en t tha t the po li cy 6was no lo ng er i n e ffec t atth e ti m e o f th e d is ab il it y . Thenitco ul d h av e co ns id ered

ot he r ba se s fo r de nyin g t he cla im . In ad di ti on , alt ho ug h i t was Met Life ’s fau ltth at th ere was no op po rtu ni ty to co rrec t thi s t hr ou gh th e ap pe al s p ro ces s, the re i s n o ev id en ce i n t he reco rdth atMet Life kn ew, at t ha t t im e th atth e d en ia l l et te r was se nt , th atitwou ldbe it s l as t o pp ortu ni ty to ad dr es s M art in ez-C la ib ’s cla im . The refo re, b ecau se th ere i s n o e vi de nc e th atMet Life in te nt io na ll y ga ve up th e rig htto rai se th es e arg um en ts , or t ha t M et Life was u nju st ly ben efi tt edby its co nduc t, the arg um en ts Met Life rai se s wer e n otwaiv ed . B. The di stric t co urt fo un d M art in ez-C la ib ’s cla im was t im e-b arre d b ecau se sh e fai le d t o c om

pl y with t he no ti ce p ro vi si on s o f th e p ol ic y . Mart in ez-C la ib st at es th atsh e b ecame dis ab le d i n M ay 20 02 , when sh e was reas si gn edto th e po si ti onof h eal th educ at or . She fil edhe r cl ai m in Marc h 2 00 4. As th e d is tri ct co urt fo un d, ev enun de r th e m os t g en ero us no ti ce p ro vi si on s o f th e p ol ic y , Marti ne z-Cl ai b’s cl ai m

is ti m e-b arre d. Th e la stde ad li ne forfil in g acla im is on e y ear f ro m th e ti m e th e p ro of

of c la im was re qu ire d t o b e fi le d, wh ic h was Nov em be r 20 03 , andth e cl ai m

was fi le d fo ur

m on th s l at er. Marti ne z-Cl ai b arg ue s t ha t d es pi te th e u nt im el y no ti ce, Fl or id a’s no ti ce-p reju di ce ru le ap pl ie s. InUNUM Life In su ran ce Co . of Am eri ca v . W ard , 7th e Supr em e Co urt fo un d t ha t Ca li fo rn ia ’s no ti ce-p reju di ce ru le was n ot

pr eem pt edby E RISA b ecau se itfel l wi th in th e st atut ory sav in gs claus e whi ch ex em pt s fr om pre em pt io n a ny sta te law wh ic h re gu la te s i ns ur an ce. 5 26 U.S. 35 8, 36 3- 64 (19 99 ). Ther efo re, i t i s l ik el y th atFlo rid a’s la w wou ldno t b e p reem pt ed . Fl or id a’s la w was arti cu la te d i n Ti ed tk e v . Fid el ity & Cas ua lt y

Co . of New Yo rk , a cas e co nc ern in g acar i ns ur an ce p ol ic y with ano ti ce p ro vi si on requi rin g t he in su redto pro vi de writ te n n ot ic e o f an y acci de nt“ as so on as p ract ic ab le .” 22 2 So .2d20 6, 2 07 (Fl a. Sup. Ct . 19 69 ). The c ou rt h el d t ha t “ whi le pre jud ic e to th e in su rer i s p res um ed , if the in su redcande m on st rat e th atth e in su rer h as no t b een pr ejud ic edth ereb y , th enth e in su rer wi ll no t b e rel ie ve d o f li ab il ity m erel y by a sh owi ng th atno ti ce was no t g iv en‘ as so on as p ract ic ab le .’ ” Id . at 2 09 . See al so Lan e v . Pro vi de ntLife & Acci de ntIns . Co., 1 78 F.Supp .2d12 81 (S.D. Fla . 20 01 ) (co ns id eri ng th e ru le in th e co nt ex t o f a d is ab il it y cla im .) Here, Ma rti ne z-Cl ai b h as no t s uf fic ie nt ly creat eda ge nu in e is su e o f m at eri al factwith re sp ectto whet he r he r ev id en ce re bu ts th e p res um pt io n t ha t M et Life was pr ejud ic edby her d el ay . If Mart in ez-C la ib ha d c om pl ie d wi th th e d ead li ne s fo r fil in g t he no ti ce o f cl ai m

or t he ti m e li m itforfil in g p ro of of c la im , Met Life wou ld m os t l ik el y

ha ve ha d n ot ic e o f th e cl ai m be fo re Marti ne z-Cl ai b’s l as t d ay of wo rk as a he al th educ at or . There fo re, i t wo ul d h av e u nd ers to odsh e was ba si ng he r 8di sabi li ty clai m on th e la stda te work edas aph y si ci anan d n otth e la stda te work ed as a he al th educ at or . AFFIR MED.

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