Court Opinion

ID: 201069
Source: CourtListenerOpinion
Date Created: 2011-02-07 05:07:03+00
Date Added: 2024-06-11T13:01:17.108009
License: Public Domain

Not For Publication in West's Federal Reporter
                Citation Limited Pursuant to 1st Cir. Loc. R. 32.3

          United States Court of Appeals
                         For the First Circuit

No. 03-2391

                         RICHARD A. COLE, M.D.,

                          Plaintiff, Appellant,

                                       v.

          CENTRAL STATES SOUTHEAST AND SOUTHWEST AREAS
                     HEALTH AND WELFARE FUND,

                          Defendant, Appellee.

          APPEAL FROM THE UNITED STATES DISTRICT COURT

                 FOR THE DISTRICT OF MASSACHUSETTS

              [Hon. Mark L. Wolf,        U.S. District Judge]

                                    Before

                        Boudin, Chief Judge,
                 Lipez and Howard, Circuit Judges.

    Richard A. Cole on brief pro se.
    Francis J. Carey on brief for appellant.

                               June 15, 2004
       Per Curiam. Pro se plaintiff-appellant Richard A. Cole, M.D.,

challenges the district court's grant of summary judgment to

defendant Central States, Southeast and Southwest Areas Health and

Welfare Fund ("Central States") and denial of his claim under

Section 502(a)(1)(B) of the Employee Retirement Income Security Act

of 1974, 29 U.S.C. § 1132(a)(1)(B), for nonpayment of benefits for

medical services    rendered   to   a     Plan   beneficiary.   We   affirm

essentially for the reasons set forth in the district court's

August 28, 2003, Memorandum and Order.           We add only that Cole has

not demonstrated that Central States' denial of his claim failed to

comply with ERISA's statutory and regulatory notice requirements,

29 U.S.C. § 1133; 29 C.F.R. § 2560.503-1(f).

       Cole argues that Central States' "mantra" of "routine physical

examination" was too conclusory to provide adequate notice of the

reason for the denial to allow him to prepare for administrative

review, and he maintains that Central States should have given him

a line-by-line explanation for its denial of each charge. However,

this level of detail is not required by the statute or regulations.

Rather, the requirements are satisfied so long as the claimant is

"supplied with a statement of reasons that, under the circumstances

of the case, permit[] a sufficiently clear understanding of the

administrator's position to permit effective review."           Halpin v.

W.W. Grainger, Inc., 962 F.2d 685, 690 (7th Cir. 1992); see id. at

689.    Central States' letters to Cole clearly indicate that his

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claim was denied because Central States' Medical Consultant found

the services for which Cole sought payment to be unnecessary and

unrelated to the diagnosis he reported, and they were therefore

excluded. The plan excluded coverage for treatment that was either

unnecessary or for routine physical examinations.              That was enough

to   satisfy   the   statutory      and   regulatory     requirements.        See

Militello v. Central States, S.E. & S.W. Areas Pension Fund, 360

F.3d 681, 689 (7th Cir. 2004) ("Although the letter is sparse, the

Trustees were required to give only specific reasons, not the

reasoning behind the reasons" (internal quotation marks omitted));

Gallo v. Amoco Corp., 102 F.3d 918, 923 (7th Cir. 1996) ("All [the

plan administrator] has to give the [claimant] is the reason for

the denial of benefits; he does not have to explain to him why it

is a good reason" (emphasis original)).

      Cole's   argument    that     Central    States   violated     the   notice

requirements    because    it   did    not     inform   him   of   the   specific

documentation or information needed to "rehabilitate" his claim is

unavailing     because    Central     States    never   suggested    that    more

information was needed to perfect the claim and allow for adequate

review.   See Terry v. Bayer Corp., 145 F.3d 28, 39 (1st Cir. 1998);

Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 236 (4th Cir.

1997); Brehmer v. Inland Steel Indus. Pension Plan, 114 F.3d 656,

661-62 (7th Cir. 1997). Central States did not reject Cole's claim

as defective; it only found that his arguments did not refute the

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opinion of its medical consultant.          It was also obvious from the

alternative disposition of the February 27, 1991, bill as untimely

submitted that, in order to successfully appeal that determination,

Cole   would   have   to    prove   that   he   submitted   it   within   the

limitations period.        His contention that he did not attempt to do

so because the notices failed to advise exactly what he needed to

produce to prevail on appeal is not an adequate excuse.            The record

demonstrates that Cole received a full and fair administrative

review.

       The judgment of the district court is affirmed.           See 1st Cir.

Loc. R. 27(c).

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