Medina v. Metropolitan Life Insurance

United States Court of Appeals
For the First Circuit
No. 08-2564
LUIS F. MEDINA,
Plaintiff, Appellant,
v.
METROPOLITAN LIFE INSURANCE COMPANY,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Gustavo A. Gelpí, U.S. District Judge]
Before
Torruella, Lipez and Howard,
Circuit Judges.
Sonia B. Alfaro de la Vega with whom Alfaro Alfaro & Acevedo-
Carlson, was on brief, for appellees.
Frank Gotay-Barquet with whom Gotay & Pérez, P.S.C., was on
brief, for appellant.
November 25, 2009
HOWARD, Circuit Judge. Plaintiff Luis Medina appeals
from the district court's entry of summary judgment in favor of
defendant Metropolitan Life Insurance Company ("MetLife"). Medina
contends that MetLife violated the Employment Retirement Security
Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., by using an
arbitrary and capricious procedure in terminating his short-term
disability benefits and refusing to grant him long-term disability
benefits. He also seeks monetary sanctions against MetLife for an
alleged breach of its disclosure obligations under 29 U.S.C.
§ 1132. The district court found no violation in either of the
benefits determinations. We affirm.
Medina worked as a maintenance technician for Abbott
Laboratories, Inc. in Puerto Rico. As an Abbott employee, he
participated in a disability insurance plan administered by Metlife
that provided both short-term and long-term disability benefits
("the Plan"). In June 2006, Medina ceased work due to obstructive
sleep apnea and high blood pressure. Shortly thereafter, he
submitted a claim for short-term disability benefits under the
Plan. His treating physician, Dr. Hector Stella, provided MetLife
a diagnostic report. On August 1, 2006, MetLife informed Medina
that it would grant him short-term disability benefits for a
limited period, but would require additional documentation before
any further benefits would be awarded. Dr. Stella submitted a
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second evaluation on August 21, 2006 containing further diagnoses
but little in the way of specific test results.
On several occasions over the next two months, MetLife
attempted to contact Medina and Dr. Stella by letter, phone, and
fax in order to explain that more specific information was
necessary and to request test results and progress notes. While
attempts to reach Dr. Stella directly were apparently unsuccessful,
Medina agreed to follow up with him about MetLife's need for
additional medical information. On November 13, 2006, Dr. Stella
submitted his progress notes covering the period from June 4, 2006
to August 16, 2006.
In early December 2006, MetLife notified Medina that it
was terminating his short-term disability benefits. In support of
its decision to terminate benefits, MetLife stated that the
information submitted by Dr. Stella was insufficient to support a
finding of full disability under the Plan's terms.1 The notice
1
Specifically, the notice stated:
We reviewed the medical progress notes of your
physician, Dr. Hector Stella Estevez, dated from June 4,
2006 to August 16, 2006. They indicate that you continue
to have high blood pressure. However, the readings
documented in the medical reports are within a normal
range. Your physician indicated a weight-loss plan but
he has not documented what the recommended plan is, what
your weight was at the start of the plan and what
progress, if any, has been made to date. Your physician
gave a diagnosis of congestive heart failure, but he has
not furnished any electrocardiogram, medical examination
findings, laboratory tests or X-rays to support that
diagnosis. Your physician reports problems with the
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also described MetLife's attempts to obtain more detailed evidence
from Dr. Stella.
In late December 2006, Medina appealed to MetLife to
reconsider its decision, and MetLife agreed to submit the claim for
independent medical review. On January 7, 2007, Medina forwarded
additional progress notes and reports from Dr. Stella detailing
symptoms, diagnoses, and treatments. MetLife referred Medina's
entire claim file to an independent medical consultant, Dr. Stephen
Kreitzer. On January 31, 2007, Dr. Kreitzer issued a report in
which he concluded that "there are insufficient clinical findings
or data to support reduction in ability to work full time or that
he cannot perform his medium work." On February 2, 2007, MetLife
again attempted to contact Dr. Stella to ask for his thoughts on
the report and, in the event of a disagreement, any evidence
supporting a contrary position. It faxed this request directly to
Dr. Stella's office, but Dr. Stella apparently never received it.
MetLife also repeatedly informed Medina that it was trying to reach
Dr. Stella and asked him to relay the message in order to assure a
response. Medina told MetLife that he had already submitted all of
his medical records and that Dr. Stella was upset because there was
C-pap machine but he does not make any other
recommendation. Although we have treatment notes since
July, no information is contained in them with respect to
physical and/or functional limitations or restrictions
that prevent you from returning to your own job as a
maintenance technician at Abbott.
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nothing left to send. By mid-March, MetLife had still heard
nothing from Dr. Stella in response to Dr. Kreitzer's report.
On March 21, 2007, after reviewing the existing medical
information, findings, clinical remarks, and Abbott policies,
MetLife concluded that the original denial of short-term disability
benefits was appropriate. It informed Medina that his benefits
would not be reinstated and that he had exhausted all available
administrative remedies on that claim.
Medina sued in the federal district court for the
District of Puerto Rico and later filed a motion in that court for
judgment on the administrative record. The district court granted
summary judgment to MetLife, and this appeal ensued.
I. Denial of Benefits
Medina maintains that he is entitled to both short-term
and long-term disability benefits. As to the former, the district
court reviewed the administrative record and determined that
MetLife did not abuse its discretion in denying the claim. As to
the latter, it found that it lacked jurisdiction because Medina had
not yet exhausted his administrative remedies. We review de novo
the district court's grant of summary judgment. Stamp v. Metro.
Life Ins. Co., 531 F.3d 84, 88 (1st Cir. 2008).
A. Short-Term Disability Benefits
Because the Plan grants MetLife discretionary authority
to determine eligibility for benefits, we will not overturn its
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decision unless it was arbitrary or capricious. Metro. Life. Ins.
Co. v. Glenn, 128 S.Ct. 2343, 2347-48 (2009); Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).2 Under this
generous standard, we inquire into whether MetLife's decision was
reasoned and supported by substantial evidence. Stamp, 531 F.3d at
88. Put differently, we will uphold MetLife's decision to deny
disability benefits "if there is any reasonable basis for it."
Wallace v. Johnson & Johnson, ___ F.3d ___, No. 09-1069, 2009 WL
3294841 at *3 (1st Cir. Oct. 14, 2009).3
Medina presents three arguments as to why MetLife's
procedures in terminating his short-term benefits should be deemed
arbitrary and capricious. None are availing.
2
The Plan states in relevant part:
In carrying out their respective responsibilities under
the Plan, the Plan administrator and other Plan
fiduciaries shall have discretionary authority to
interpret the terms of the Plan and to determine
eligibility for and entitlement to Plan benefits in
accordance with the terms of the Plan. Any
interpretation or determination made pursuant to such
discretionary authority shall be given full force and
effect, unless it can be shown that the interpretation or
determination was arbitrary and capricious.
3
Medina argues that a less deferential standard of review
should apply, notwithstanding the Plan's grant of discretionary
authority to MetLife, because a "serious procedural irregularity
existed" that "caused a serious breach of the plan administrator's
fiduciary duty." Woo v. Deluxe Corp., 144 F.3d 1157, 1160 (8th
Cir. 1998). Even if we were to subscribe to such a rule, we find
no such irregularity here.
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First, he alleges that Dr. Kreitzer based his evaluation
on false assumptions concerning the extent of his occupational
demands. A MetLife case manager had originally classified the
maintenance technician work that Medina performed as a "heavy" job.
Yet when Dr. Kreitzer issued the report on which MetLife relied, he
stated that "there are insufficient clinical findings or data to
support reduction in ability to work full time or that he cannot
perform his medium work." (Emphasis added). Medina now argues for
the first time that the description of his job duties as "medium
work" shows that Dr. Kreitzer premised his recommendation on the
belief that Medina's occupation was less demanding than it actually
was. By failing to raise this argument in either the claims
process or the district court, however, Medina has waived it on
appeal. Lugo-Velazquez v. Stiefel Labs., Inc. 522 F.3d 96, 99 (1st
Cir. 2008); Campbell v. BankBoston, N.A., 327 F.3d 1, 10 (1st Cir.
2003). We therefore do not address it.
Second, Medina claims that MetLife did not accord
sufficient weight to Dr. Stella's evaluations in considering
whether his physical impairment met the Plan's definition of "full
disability." Yet "courts have no warrant to require administrators
automatically to accord special weight to the opinions of a
claimant's physician; nor may courts impose on plan administrators
a discrete burden of explanation when they credit reliable evidence
that conflicts with a treating physician's evaluation." Black &
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Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). "[A]
plan administrator is not obligated to accept or even to give
particular weight to the opinion of a claimant's treating
physician." Morales-Alejandro v. Med. Card Sys., Inc., 486 F.3d
693, 700 (1st Cir. 2007). Consequently, "in the presence of
conflicting evidence, it is entirely appropriate for a reviewing
court to uphold the decision of the entity entitled to exercise its
discretion." Gannon v. Metro. Life Ins. Co., 360 F.3d 211, 216
(1st Cir. 2004).
In this case, Dr. Kreitzer had substantive reasons for
diverging from Dr. Stella's assessment. In his report, Dr.
Kreitzer noted that most of the medical information that Medina had
provided through Dr. Stella was not recent; that many significant
diagnostic tests had not been performed; that it is very rare for
sleep apnea to cause impairment; and that there were insufficient
clinical findings or data to support reduction in work ability. We
conclude that these findings by an independent medical examiner
gave MetLife the requisite "substantial evidentiary grounds for a
reasonable decision in its favor." Denmark v. Liberty Life Assur.
Co. of Boston, 566 F.3d 1, 6 (1st Cir. 2009)(citation omitted).
Third, Medina claims that MetLife was required to wait
for Dr. Stella to offer his feedback on Dr. Kreitzer's report
before reaching a final determination. MetLife alleges that it
faxed a copy of the report to Dr. Stella along with a solicitation
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for his review. The fax itself is contained in the administrative
record. Medina nevertheless avers that the fax must not have ever
successfully reached its intended destination. According to
Medina, any decision that did not incorporate Dr. Stella's
additional feedback can only be viewed as arbitrary because MetLife
must have considered that feedback to be absolutely necessary;
otherwise, Medina argues, MetLife would not have attempted to
solicit Stella's reaction to begin with.
The record, however, indicates that Medina was on ample
notice that MetLife was trying to reach Dr. Stella. Through
multiple letters and phone calls, MetLife made clear to Medina that
it was attempting to obtain more detailed information from his
physician. Dr. Stella had multiple opportunities to present
evidence to rebut Dr. Kreitzer's findings. He instead remained
silent. If, as we have already observed, an administrator is not
obliged to place particular weight on the opinion of a claimant's
treating physician, then we cannot see how an administrator could
have an obligation to wait indefinitely for an opinion that is not
forthcoming. When the treating physician fails to respond to
repeated requests for further data, the administrator is entitled
to review the information available, so long as that information
provides a sufficient basis to make a reasonable determination.
Such was the case here. It was not as though MetLife
lacked the benefit of Dr. Stella's observations entirely. At the
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time MetLife rendered its decision, it had reviewed Dr. Stella's
progress notes dated June 4, 2006 to August 16, 2006, as well as
his January 7, 2007 report. Indeed, the record indicates that Dr.
Stella himself felt that there was nothing left for him to submit.
Though MetLife was evidently willing to consider other information
if it became available, it had the prerogative to reach a
conclusion based on the existing reports from Dr. Stella and Dr.
Kreitzer.
B. Long-Term Disability Benefits
A plaintiff who wishes to raise an ERISA claim in federal
court must first exhaust all administrative remedies that the
fiduciary provides. Madera v. Marsh USA, Inc., 426 F.3d 56, 61
(1st Cir. 2005). The district court found that Medina had failed
to do so with respect to his request for long-term disability
benefits because he had never actually submitted a benefits claim
for evaluation and adjudication. We review this finding of fact
for clear error. Green v. ExxonMobil Corp., 470 F.3d 415, 418 (1st
Cir. 2006).
Medina does not attempt to rebut the district court's
conclusion with any direct evidence that he did in fact submit a
long-term disability benefits claim. Instead, he asks us to infer
as much circumstantially from two events described in the
administrative record: (1) on June 15, 2006, Medina signed a form
in which he agreed to remiburse Abbott Laboratories for any
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overpayment on long-term disability benefits; and (2) in an October
26, 2006 letter to Medina, MetLife used the phrase "in reference to
your long-term disability claim." Based on these two documents,
Medina maintains that both his employer and MetLife "expressly
recognize" that he had submitted claims for long-term disability
benefits, and thus that he would have exhausted his administrative
remedies.
We do not find this evidence to be persuasive. Medina
consistently and conspicuously avoids any affirmative statement
that he actually filed the phantom claim, trying to carry his
burden purely through the words of others. Yet those words are not
nearly as significant as Medina argues. The June 15 agreement
appears to be a boilerplate form which includes sections for both
short-term and long-term disability benefits. Nowhere does it
state that Medina actually lodged a claim for long-term disability
benefits specifically. As for the October 26 letter, to the extent
that it suggests that a claim was filed, we think Medina's own
subsequent communications prove otherwise. On July 2, 2007,
Medina's attorney wrote a letter to a member of MetLife's Benefits
Department in which he expressed interest "in applying and
requesting benefits under the Long Term Disability (LTD) plan" and
requesting "any instructions and information necessary to proceed
with an application." This letter weighs heavily against Medina's
circumstantial proffer. In light of this communication, along with
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the complete absence in the record of any persuasive evidence that
Medina ever filed the claim to which he refers, the district court
did not clearly err in finding that Medina failed to exhaust his
administrative remedies.
II. Disclosure Obligations
In a separate argument, Medina contends that MetLife's
failure to provide him with a copy of the fax to Dr. Stella
constituted a sanctionable violation of its disclosure obligations
under 29 U.S.C. § 1132(c)(1)(B). That section provides in
pertinent part:
Any administrator . . . who fails or refuses
to comply with a request for any information
which such administrator is required by this
subchapter to furnish to a participant or
beneficiary . . . by mailing the material
requested to the last known address of the
requesting participant or beneficiary within
30 days after such request may in the court's
discretion be personally liable to such
participant or beneficiary in the amount of up
to $100 a day from the date of such failure or
refusal, and the court may in its discretion
order such other relief as it deems proper.
On April 12, 2007, Medina wrote to MetLife requesting all
relevant documents on which it had relied in reaching its decision
to deny short-term disability benefits. He specifically asked for
a copy of the fax sent to Dr. Stella, along with a confirmation
page showing that the fax had successfully been transmitted. On
April 25, 2007, MetLife sent Medina the entire case file. Medina's
claim on appeal is that because this file did not contain the
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requested transmission confirmation sheet (the fax itself was
produced), MetLife is liable for sanctions under § 1132.
Medina's conclusion is a non sequitur. First, the remedy
he seeks is not available for his alleged grievance. The
substantive requirement that MetLife furnish requested documents
after a denial of a claim is located in § 1133, which obligates
insurance plans to "afford a reasonable opportunity to any
participant whose claim for benefits has been denied for a full and
fair review by the appropriate named fiduciary of the decision
denying the claim." 29 U.S.C. § 1133(2); see also 29 C.F.R.
§ 2560.503-1(h)(2)(iii) (delineating requirements for a "full and
fair review"). It is well established that a violation of § 1133
and its implementing regulations does not trigger monetary
sanctions under § 1132(c). See, e.g., Wilczynski v. Lumbermens
Mut. Cas. Co., 93 F.3d 397, 406 (7th Cir. 1996); Sturhlreyer v.
Armco, Inc. 12 F.3d 75, 79(6th Cir. 1993); Groves v. Modified Ret.
Plan, 803 F.2d 109, 117-18 (3d Cir. 1986). Sanctions are therefore
unavailable here.
Second, even if sanctions were available, we see no foul
that would merit them. Section 1133's implementing regulation
provides:
[T]he claims procedures of a plan will not be
deemed to provide a claimant with a reasonable
opportunity for a full and fair review of a
claim and adverse benefit determination unless
the claims procedures . . . [p]rovide that a
claimant shall be provided, upon request and
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free of charge, reasonable access to, and
copies of, all documents, records, and other
information relevant to the claimant's claim
for benefits.
29 C.F.R. § 2560.503-1(h)(2)(iii). MetLife, which mailed the
entire claim file a week after receiving Medina's request, more
than sufficiently met the regulation's "reasonable access"
standard. Although Medina demands a fax transmission confirmation
in addition to the fax itself, there is no reason to think that
such a document was ever part of the file, and its absence is not
a violation.
III. Attorney's Fees
Finally, Medina argues that the district court erred in
not awarding him attorney's fees. "[W]e will disturb such rulings
only if the record persuades us that the trial court indulged in a
serious lapse in judgment." Twomey v. Delta Airlines Pilots
Pension Plan, 328 F.3d 27, 33 (1st Cir. 2003). These awards are,
of course, "normally for the prevailing party." Doe v. Travelers
Ins. Co., 167 F.3d 53, 60 (1st Cir. 1999). Because we conclude
that Medina does not prevail on any of his substantive claims, we
affirm the district court's denial of Medina's request for fee-
shifting.
Affirmed.
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