Opinion ID: 212482
Heading Depth: 2
Heading Rank: 2

Heading: Use of Medical Information

Text: As we have noted, a disability review must be “principled,” that is, authorized under ERISA and conducted in accordance with its terms. Palmer claims that MetLife’s actions were essentially unprincipled because the Plan only permitted MetLife to request and use “current” medical records in reaching a decision to terminate benefits. He argues “current” means “recent,” see Aplt. Opening Br. at 19, and therefore MetLife was not authorized to request or rely on records that existed at the time it initially approved his claim. We note, first, that the Plan provisions Palmer cites only concern MetLife’s right to obtain current medical information from him, not use of that information once it has been obtained. By voluntarily providing MetLife with the records of his consultations with Dr. Turner, Palmer waived any claim that MetLife was unauthorized to obtain the records from him. Cf. Allison v. UNUM Life Ins. Co., 381 F.3d 1015, 1024 (10th Cir. 2004) (refusing to consider whether insurer acted beyond scope of plan by (a) requesting additional releases for medical information dating nearly two years before coverage period, (b) resulting from insurer’s initial -13- miscalculation of pre-existing condition period, then (c) denying benefits based on pre-existing condition when releases were not received; where claimant’s attorney “did not protest” scope of releases and did not “write back and indicate his refusal to comply with the extensive request”). 4 Moreover, having received relevant and unquestionably authentic records in connection with its review, MetLife did not act unreasonably in relying on them. The Plan did not restrict MetLife’s use of medical records in connection with a principled review. Under the Plan, MetLife had the right to consider “Proof” of disability in support of a claim, which was defined to include information relating to “the claimant’s right to receive payment.” Aplt. App., Vol. III at A764. We therefore reject Palmer’s claim that MetLife conducted its review in an unprincipled fashion by obtaining and relying on records of his previous consultations with Dr. Turner. 4. Underpayment of Benefits Finally, Palmer argues that if his disability benefits were indeed terminated effective March 1, 2008, he was entitled to the full amount of benefits that had accrued to that point and that had become due and payable upon MetLife’s initial approval of his claim. MetLife does not seek recovery of benefits already paid to 4 Our determination on this issue forecloses Palmer’s additional argument that MetLife’s letter to him about its right to seek records to demonstrate his continued eligibility could not have expanded its authorization under the Plan to request “old” or “existing” medical records as well as “future” records. See Aplt. Opening Br. at 23-24. -14- Palmer. But since there is no dispute that MetLife failed to pay him benefits calculated based on both his base salary and commissions, as required by the Plan, he contends MetLife must make good the underpayment to the date of termination. The district court addressed this issue briefly, reasoning as follows: [P]laintiff seeks payment of additional benefits on the basis that MetLife miscalculated the amount of his payments while he was receiving benefits. MetLife responds that plaintiff is not eligible for a recalculation because the benefits plaintiff received were overpayments and plaintiff should not have received those payments because his condition was preexisting. The court finds that this decision was reasonable based on the record. Aplt. App., Vol. I at A159. Palmer fails to point us to any precedent in support of his argument that MetLife’s erroneous determination obligates it to pay him benefits that are unquestionably barred by the Plan language. He cannot claim benefits under the Plan’s plain language, which excludes such payment for what he concedes is a pre-existing condition. At best, he has an argument that MetLife is estopped by its own prior erroneous determination and its payment of benefits from denying his entitlement to the full amount of those benefits. Our cases hold that coverage under a plan subject to ERISA cannot be expanded by estoppel. The insured’s reliance on an administrator’s oral and written statements cannot create coverage, because it is the language of the plan that controls the entitlement to benefits. See, e.g., Alexander v. Anheuser-Busch Cos., 990 F.2d 536, 539 (10th Cir. 1993); Miller v. Coastal Corp., 978 F.2d 622, -15- 624-25 (10th Cir. 1992) (miscalculation of estimated benefits in annual statements not binding under equitable estoppel theory). This case differs somewhat from these precedents, in that here the claim for additional benefits is based on MetLife’s own formal decision awarding benefits. But even if estoppel may be predicated on such a decision, Palmer fails as a matter of law to show his entitlement to it. In order to make out a claim of estoppel under ERISA, there must be: 1) conduct or language amounting to a representation of material fact; 2) awareness of the true facts by the party to be estopped; 3) an intention on the part of the party to be estopped that the representation be acted on, or conduct toward the party asserting the estoppel such that the latter has a right to believe that the former’s conduct is so intended; 4) unawareness of the true facts by the party asserting the estoppel; and 5) detrimental and justifiable reliance by the party asserting estoppel on the representation. Armistead v. Vernitron Corp., 944 F.2d 1287, 1298 (6th Cir. 1991). Under the facts of record, Palmer cannot meet either the fourth or fifth criteria for estoppel. He does not deny (and cannot reasonably deny) that his back problems constituted a pre-existing condition under the terms of the Plan. During the time MetLife was paying him benefits for his condition, he was on notice of both the Plan’s definition of a pre-existing condition and of the visits he had made to Dr. Turner for his back condition during the disqualification period. While he received a windfall from MetLife’s inexplicably favorable decision on his pre-existing condition, he fails to show an equitable entitlement to additional -16- benefits based on any sort of reasonable reliance. We therefore affirm the district court’s decision denying him additional benefits. The judgment of the district court is AFFIRMED. Entered for the Court Deanell Reece Tacha