Cole v. Central States

Not For Publication in West's Federal Reporter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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