Court Opinion

ID: 4382604
Source: CourtListenerOpinion
Date Created: 2019-03-29 21:00:12.643209+00
Date Added: 2024-06-11T12:03:41.469410
License: Public Domain

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."

                                        - 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 -