Rodriguez-Lopez v. Triple-S Vida, Inc.

United States Court of Appeals
For the First Circuit
No. 15-2413
NILDA RODRÍGUEZ-LÓPEZ,
Plaintiff, Appellant,
v.
TRIPLE-S VIDA, INC.,
Defendant, Appellee.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Bruce J. McGiverin, U.S. Magistrate Judge]
Before
Torruella, Thompson, and Kayatta,
Circuit Judges.
Víctor Gratacós-Díaz, with whom Gratacós Law Firm, PSC was on
brief, for appellant.
Diana Pérez-Seda, with whom César T. Alcover and Casellas
Alcover & Burgos, PSC were on brief, for appellee.
March 1, 2017
TORRUELLA, Circuit Judge. Plaintiff-appellant Nilda
Rodríguez-López ("Rodríguez") appeals from the district court's
grant of summary judgment in favor of defendant-appellee Triple-S
Vida, Inc. ("Triple-S"). The district court reviewed and
sustained Triple-S's denial of Rodríguez's claim for long-term
disability ("LTD") benefits under the deferential arbitrary and
capricious standard. Because the plan contained no clear
delegation of authority to Triple-S, we hold that Triple-S's
decision was not entitled to deference. Accordingly, we reverse
and remand to the district court to decide the case under the
de novo standard of review.
I. Factual Background
The following facts have been drawn largely from the
district court's opinion in this case.
A. Rodríguez's History
Rodríguez, a licensed chemist, worked as a senior
chemist/quality control laboratory supervisor for Mova
Pharmaceutical Corporation ("Mova") from 1995 to 2004. Her job
required her to perform some physical activity, such as standing,
walking, bending, reaching, lifting, carrying, and writing.
Rodríguez first started to experience symptoms on
March 12, 2004 -- which was also her last day of work -- and was
then diagnosed with several physical and mental conditions. She
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was prescribed medications to mitigate some of the symptoms. She
subsequently underwent a series of medical exams and began
treatment with Dr. Héctor J. Cases, a neurologist, in June 2004.
Dr. Cases filled out a "Functional Capacity Estimate" form on
November 29, 2004, where he concluded that she could not work full-
time or part-time, even if her employer accommodated her
limitations and restrictions. Accordingly, Rodríguez filed a
claim for disability benefits under Mova's LTD plan.
B. Plan Provisions
Mova's LTD plan is an employee welfare benefits plan
governed by the Employee Retirement Income Security Act of 1974
("ERISA"), 29 U.S.C. §§ 1001 et seq. Jefferson-Pilot Life
Insurance Company ("Jefferson-Pilot") originally issued a group
policy (the "Plan") to Mova. The summary plan description ("SPD")
named Mova as the Plan sponsor and administrator, and stated that
"[t]he Plan Sponsor is granted the discretionary authority to
determine eligibility for benefits and to construe the terms of
the Plan."
Under the Plan, the forms to claim benefits and proof of
loss for a disability were to be submitted to Jefferson-Pilot.
Jefferson-Pilot had the right, at its own expense, to examine the
claimant, when and as often as was reasonably required while the
claim was pending. If the claim was wholly or partially denied,
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Jefferson-Pilot would furnish a written notice that stated the
specific reasons for the denial and the basis in the Plan
provisions, explain the Plan's claim review procedures, and
describe any additional material or information needed to
reconsider the decision. Also, an officer designated by
Jefferson-Pilot would review requests for review of a claim, and
Jefferson-Pilot would furnish a written decision.
Triple-S claims that at some point it replaced
Jefferson-Pilot in the contractual relationship between Mova and
Jefferson-Pilot and that it notified Mova that Triple-S would pay
the benefits provided under the Plan, subject to all the policy's
provisions. Thereafter, all the things that the Plan stated would
be performed by Jefferson-Pilot were actually performed by Triple-
S. The Plan, however, was not amended to reflect this change.
Nor was a new SPD or summary of material modifications furnished
to plan participants notifying them of this change and naming
Triple-S as claims administrator and/or insurer.
The Plan offered LTD benefits due to total disability.
To qualify for these benefits, the beneficiary had to comply with
the Plan's definition of "total disability" or "totally disabled"
and be under a doctor's care during the entire time of the total
disability. "'Total disability' . . . means . . . that you are
unable to perform all of the material and substantial duties of
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your occupation on a full-time basis because of disability:
(1) caused by injury or sickness; and (2) that started while you
are insured." A beneficiary is "totally disabled" if she is
"unable to perform with reasonable continuity all of the material
and substantial duties of [her] own or any other occupation for
which [she is] or become[s] reasonably fitted by training,
education, experience, age[,] and physical and mental capacity."
Benefits would be paid when the beneficiary is totally disabled
for longer than the applicable Elimination Period until the
earliest of: (1) the day the total disability ends, (2) death, or
(3) the end of the maximum payment period. For mental illness,
however, the plan limited payment of benefits to twenty-four
months.1
C. Rodríguez's Claim for LTD Benefits
Triple-S received Rodríguez's application for LTD
benefits on January 13, 2005.2 She claimed to be experiencing
various symptoms which rendered her unable to work. She stated
that she did not anticipate working in the near future, either in
her previous occupation or in any other occupation, and was not
1 Benefits for mental illness could be extended longer than
twenty-four months under certain conditions not present here.
2 The claim was dated December 9, 2004.
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interested in getting training or in working in another type of
occupation or work activity.
Rodríguez's claim was initially denied, but it was later
approved on administrative appeal once Rodríguez supplemented her
record with additional evidence. Her LTD benefits were granted
on October 10, 2005, under the mental illness disability provision
of the Plan, but it was effective retroactively to September 24,
2004. Since the Plan provided that disability benefits due to
mental illness could be granted for a maximum term of twenty-four
months, Rodríguez's mental-illness benefits expired September 24,
2006. Rodríguez was not awarded LTD benefits for her physical
ailments, but she was notified that her physical condition would
be further investigated.
From 2007 to 2012, Rodríguez was notified on various
occasions that her claim for LTD benefits for physical disability
was being evaluated, as the Plan's twenty-four-month term for
mental illness had expired. During this time period, Triple-S
continued issuing the same monthly disability payments Rodríguez
had been receiving for her mental illness. On December 16, 2009,
the Social Security Administration found Rodríguez to be disabled,
retroactive to March 12, 2004. Rodríguez submitted evidence of
her Social Security claim to Triple-S. Since Social Security
benefits were to be deducted from the amount payable for disability
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under the Plan, Triple-S requested a refund of all excess LTD
benefits.
Rodríguez also submitted updated copies of progress
notes from her treating physicians, including her rheumatologist
and endocrinologist, which stated that she was unable to perform
a gainful job since her disability was permanent and total. After
further medical exams were performed on Rodríguez, her
neurologist, Dr. Cases, filled out additional "Functional Capacity
Estimate" forms on February 9, 2009, and January 18, 2013, where
he stated that Rodríguez was not able to work full-time or part-
time. He certified that Rodríguez was completely disabled, that
she had reached the maximum medical improvement, and that she was
not fit to return to work, despite any work accommodations
available for her limitations and restrictions. Rodríguez also
filled out and submitted various Triple-S resource questionnaires,
in which she stated her symptoms and claimed to be unable to work
because her conditions were permanent.
Triple-S referred Rodríguez's case to Dr. Alfonso Bello,
a rheumatologist, for an Independent Medical Review of her medical
file. After reviewing the medical file provided to him, Dr. Bello
concluded that, from a rheumatologic perspective, Rodríguez's
medical record did not support a finding that she suffered from an
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active and disabling disorder, and, hence, she was not totally
disabled.
Triple-S also referred the case to a Vocational
Specialist for an Employability Evaluation from a physical
standpoint. The Vocational Specialist found that there were 162
sedentary and light duty occupations, including her previous job,
available in the San Juan, Caguas, and Guaynabo metropolitan area,
which Rodríguez could perform given her education, training, and
previous work experience, and that met or exceeded her reasonable
wage of $12.62 per hour. Some of these jobs are similar to the
work she performed at Mova, including technical and supervisory
duties in laboratories.
D. Denial of Claim and Administrative Appeal
On July 23, 2013, Triple-S denied Rodríguez's
application for LTD benefits, finding she no longer met the Plan's
definition of disabled. According to Triple-S, her administrative
record did not contain enough clinical evidence to support a
finding that she was unable to physically perform the tasks of her
previous job or any other occupation. Triple-S also terminated
her mental illness disability benefits, as the benefits had been
paid beyond the twenty-four-month limit allowed by the Plan. It
did not request reimbursement for the excess benefits paid.
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In accordance with the Plan's internal appeal process,
on August 23, 2013, Rodríguez administratively appealed Triple-
S's decision and submitted new evidence, copies of her medical
files, and Social Security documents. Rodríguez underwent
additional medical exams that suggested deterioration of an injury
when compared to the same study conducted in 2004.
Triple-S referred the case to Dr. Inocencio A. Cuesta,
an internist with a sub-specialty in adult rheumatology, who
performed an independent peer review on October 11, 2013.
Dr. Cuesta noted that, although the record sustained subjective
evidence of pain and evidence of a rheumatologic condition, there
was no objective evidence that indicated these findings impaired
Rodríguez. He opined that the record contained no clinical
information as to how her physical ailments affected her ability
to return to work and concluded that Rodríguez did not suffer from
physical deterioration based on a rheumatoid condition that would
prevent her from working full-time in a light or sedentary
occupation.
Another employability evaluation was conducted, taking
into account only her physical condition. The occupational
specialist concluded that there were jobs that Rodríguez could
perform given her education and experience that might not require
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additional training, modification, or restructuring, and that
would meet or exceed her reasonable wage of $12.62 per hour.
On December 3, 2013, Triple-S notified Rodríguez that it
was denying benefits because the medical record did not support a
finding that she suffered from a physical condition that prevented
her from performing light or sedentary occupations, and that
disability benefits under the mental illness provision of the LTD
plan had already been exhausted, even if she continued to be
disabled due to a mental health condition. She was also advised
of her right to sue under § 502(a) of ERISA since she had already
exhausted the administrative remedies.
E. Procedural Background
On May 21, 2014, Rodríguez filed suit in a Puerto Rico
state court. Triple-S removed the action to the federal district
court. The parties cross-moved for summary judgment. On
September 30, 2015, the district court granted Triple-S's motion
and denied Rodríguez's cross-motion. In granting Triple-S's
motion, the district court found that
[u]pon review of the group policy, administrative
documents, and related correspondence between
Rodríguez, her treating physician, her legal
representatives, and Triple-S, it is clear that
Triple-S had discretionary authority to determine
benefits eligibility. Under 29 U.S.C. § 1002(21)
(A)(iii), although Mova was designated as plan
administrator of the employee benefit plan, Triple-S
was plan fiduciary with administrative authority to
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interpret the terms of the plan and determine
eligibility for and entitlement to plan benefits.
Rodríguez-López v. Triple-S Vida, Inc., No. 14-1498, 2015 WL
5792621 at *3 (D.P.R. Sept. 30, 2015). It therefore applied the
arbitrary and capricious standard of review. Under this
deferential standard, the district court concluded that, in light
of the medical evidence in the administrative record, Triple-S's
denial of LTD benefits for physical illness was reasonable and
based on substantial evidence and, consequently, was neither
arbitrary nor capricious.
On appeal, Rodríguez contends that the district court
employed an incorrect standard of review and that the denial of
LTD benefits was insupportable under the more stringent de novo
standard.
II. Discussion
A. Applicable Law
The question of what standard of review is applicable to
a benefits decision governed by ERISA is a question of law that
this Court reviews de novo. Maher v. Mass. Gen. Hosp. Long Term
Disability Plan, 665 F.3d 289, 291 (1st Cir. 2011) (citing Smart
v. Gillette Co. Long–Term Disability Plan, 70 F.3d 173, 178 (1st
Cir. 1995)).
"[T]he rights and responsibilities of parties in
relation to employee pension and welfare plans" are regulated by
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ERISA. Terry v. Bayer Corp., 145 F.3d 28, 34 (1st Cir. 1998).
ERISA provides a cause of action for plan participants, and other
beneficiaries, to recover benefits due to them under the terms of
the Plan. See 29 U.S.C. § 1132(a)(1)(B). "It is under this
statutory provision that claims, such as this one, challenging
denials and termination of employer-sponsored disability benefits
are brought." Terry, 145 F.3d at 34.
ERISA does not establish the standard of review which
courts should apply when reviewing determinations made regarding
benefits claims. However, the Supreme Court has held that a denial
of benefits challenged "is to be reviewed under a de novo standard
unless the benefit plan gives the administrator or fiduciary
discretionary authority to determine eligibility for benefits or
to construe the terms of the plan." Firestone Tire & Rubber Co.
v. Bruch, 489 U.S. 101, 115 (1989); see also Stephanie C. v. Blue
Cross Blue Shield of Mass. HMO Blue, Inc., 813 F.3d 420, 427 (1st
Cir. 2016) ("The default rule favors de novo review . . . ."). If
the plan gives the plan participant or covered beneficiary adequate
notice of such reservation, then "a deferential arbitrary and
capricious or abuse of discretion standard" is applied. Gross v.
Sun Life Assur. Co. of Can., 734 F.3d 1, 11 (1st Cir. 2013)
(internal quotation marks omitted) (quoting Maher, 665 F.3d at
291); see also id. at 14; Stephanie C., 813 F.3d at 427 (noting
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that discretionary authority "must be expressly provided for, and
notice of that reservation must appropriately be given to Plan
participants" for the deferential standard to apply) (internal
citations omitted). "[T]he threshold question in determining the
standard of review is whether the provisions of the benefit plan
at issue 'reflect a clear grant of discretionary authority to
determine eligibility for benefits.'" Gross, 734 F.3d at 13
(quoting Leahy v. Raytheon Co., 315 F.3d 11, 15 (1st Cir. 2002)).
Although "[t]here are no required 'magic words,'" id. (quoting
Brigham v. Sun Life of Can., 317 F.3d 72, 81 (1st Cir. 2003)), "to
secure discretionary review, a plan administrator must offer more
than subtle inferences drawn from . . . unrevealing language," id.
at 16.
B. Analysis
The parties disagree on the standard of review that the
district court should have applied in reviewing Triple-S's denial
of Rodríguez's claim for benefits. Rodríguez alleges that the
Plan did not reflect a clear grant of authority to Triple-S to
make eligibility determinations under the Plan because such
authority was explicitly delegated to Mova. She alleges that if,
as the district court found, this discretionary authority was at
some later time transferred to Triple-S, this would have
constituted a "contractual violation," since the Plan required an
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amendment to change its provisions and no amendment was "found in
[Triple-S's] administrative record." Thus, her argument goes,
because it is not clear that Triple-S has been granted
discretionary authority under the Plan, its determination to deny
her LTD benefits was subject to the de novo standard of review.
Accordingly, she requests that the case be remanded to the district
court so that Triple-S's determination be reviewed under the
de novo standard.
In assessing whether a plan reflects a clear grant of
discretionary authority, 3 "we review the language of the Plan
de novo, just as we would review the language of any contract."
Stephanie C., 813 F.3d at 428 (quoting Ramsey v. Hercules Inc., 77
F.3d 199, 205 (7th Cir. 1996)). A careful review of the language
of the Plan leads us to conclude that it does not reflect a clear
grant of discretionary authority to Triple-S to determine
eligibility for benefits.
3 Triple-S alleges that we need not analyze this because, by
arguing in the district court that Triple-S abused its discretion
in denying her claim for benefits, Rodríguez waived any argument
that the applicable standard of review should have been de novo.
Although Triple-S acknowledges that Rodríguez also argued in her
motion for summary judgment that Mova was the plan administrator
and that Triple-S had no authority to make eligibility
determinations, Triple-S claims that this argument "was not tied
to a rejection of the abuse of discretion standard." We note that
the district court found Rodríguez had sufficiently preserved her
standard of review argument, and we find so as well.
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Triple-S has not been able to point to any Plan language
specifically establishing that it (Triple-S) had discretionary
decisionmaking authority. Rather, it argues that the Plan grants
this authority to Mova but, because Triple-S was actually making
the benefit decisions in place of Mova, it is implied that the
discretionary authority has been transferred to Triple-S. Case
law, however, requires that the delegation of discretionary
authority to an administrator or fiduciary be clearly stated in
the plan. See id. at 428 (finding language in plan certificate
"not sufficiently clear to give notice to either a plan participant
or covered beneficiary that the claims administrator enjoys
discretion in interpreting and applying plan provisions"); Gross,
634 F.3d at 14 ("[T]he critical question is whether the plan gives
the employee adequate notice that the plan administrator . . . has
the latitude to shape the application, interpretation, and content
of the rules in each case." (quoting Díaz v. Prudential Ins. Co.
of Am., 424 F.3d 635, 637 (7th Cir. 2005)). The Plan fails to
meet this degree of clarity since it states that Mova, not Triple-
S, had this authority. If Triple-S wanted to benefit from the
delegation of authority and the deferential standard it provides,
the Plan needed to clearly state it4 so that Plan participants,
4 Because here a notice of a reservation of discretionary
decisionmaking authority as to Triple-S was not made in any way or
in any document, we need not decide whether it can be effected
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such as Rodríguez, received adequate notice that Triple-S had been
granted discretionary authority to interpret the Plan. There is
no evidence in the record that this was done. See Stephanie C.,
813 F.3d at 429, n.3 (finding that ambiguity as to whether the
claims administrator had discretionary authority could not be
cured by document defining relationship between the employer and
the claims administrator because there was no evidence that the
document was ever disclosed to plan participants, and noting that
plan participant "had no obligation to go in search of undelivered
documents in order to ascertain whether [the claims administrator]
had reserved for itself discretionary decisionmaking authority");
see also Maher, 665 F.3d at 291 ("absent a proper delegation, the
. . . Plan could not rely on [grant of discretionary authority to
plan sponsor] to defend a denial by an independent entity"); Terry,
145 F.3d at 37 (finding plan sponsor effectively delegated
discretionary authority to Benefit Committee following plan-
outlined procedure, and so Committee's decision subject to abuse-
of-discretion review).
Triple-S also argues that its delegation of
discretionary authority is "clear" because the Plan "undoubtedly
only through the Plan itself. See Stephanie C., 813 F.3d at 429
n.4.; Maher, 665 F.3d at 301 (Lipez, J., dissenting) (citing
Ringwald v. Prudential Ins. Co., 609 F.3d 946, 948-49 (8th Cir.
2010), which disregarded grant of discretionary authority that
appeared only in the SPD).
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establishes that Triple-S Vida's role is to grant and deny benefits
both after an initial review and after an administrative appeal
and contains detailed specifications as to how Triple-S Vida will
make [these] determinations." Contrary to Triple-S's assertions,
the Plan establishes that Jefferson-Pilot, and not Triple-S, has
the role to grant or deny benefits. Although Triple-S claims that
it is Jefferson-Pilot's successor, the Plan was not amended to
reflect this change. Nevertheless, we need not determine what
consequence, if any, this failure to amend may have because even
if we were to read "Triple-S" into the Plan where "Jefferson-
Pilot" appears, the Jefferson-Pilot provisions only give
Jefferson-Pilot the power to determine whether or not "benefits
. . . are due." The power to decide does not necessarily imply
the existence of discretion. See Stephanie C., 813 F.3d at 428;
Díaz, 424 F.3d at 637 (noting that because "[a]ll plans require an
administrator first to determine [eligibility for benefits] before
paying them[,] . . . the fact that an administrator is deciding on
a case-by-case basis who is entitled to benefits does not reveal
whether a plan does or does not reserve 'discretion' to the
administrator"). Here the Jefferson-Pilot provisions grant the
power to decide, but no more -- the provisions do not grant
discretionary authority. See Stephanie C., 813 F.3d at 428
(finding that "[plan administrator] decides which health care
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services . . . are medically necessary" clause did not grant
discretionary authority and "merely restates the obvious: that no
benefits will be paid if [the administrator] determines they are
not due"); Gross, 734 F.3d at 12-15 (holding formulation "[p]roof
[of claim] must be satisfactory to [claims administrator]"
insufficient to confer discretionary authority) (second alteration
in the original); Heasley v. Belden & Blake Corp., 2 F.3d 1249,
1254-56 (3d Cir. 1993) (holding formulation that claims
administrator "will evaluate the proposed admission for
certification of medical necessity and appropriateness under the
terms of the [policy]" similarly insufficient).
Finally, Triple-S argues that it has been granted
discretionary authority because the Plan recognizes the existence
of plan fiduciaries and it is a Plan "fiduciary with administrative
authority to interpret the terms of the plan and determine
eligibility for and entitlement to plan benefits." Rodríguez-
López, 2015 WL 5792621 at *3. This, it argues, is evidenced by
several provisions of the policy that vest Triple-S with authority
to examine the claimant as often as reasonably required; furnish
notices of denial of benefits, specifying the reasons for the
denial, informing of review procedures and describing additional
materials that could be submitted for review; and appoint an
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administrative review officer to make final determinations as to
eligibility. Its argument fails.
Named fiduciaries may be granted discretionary
decisionmaking authority. See 29 U.S.C. § 1105(c)(1); Rodríguez-
Abreu v. Chase Manhattan Bank, N.A., 986 F.2d 580, 584 (1st Cir.
1993). In such a case, however, the Plan's language must clearly
grant this authority. See Stephanie C, 813 F.3d at 428; Rodríguez-
Abreu, 986 F.2d at 583-84. ERISA also "allows named fiduciaries
to delegate responsibilities (other than trustee responsibilities)
through express procedures provided in the plan." Rodríguez-
Abreu, 986 F.2d at 584 (citing 29 U.S.C. § 1105(c)(1)). For the
delegation of discretionary authority to be effective so that the
deferential standard of review applies, however, the delegation
must be clear and the fiduciary must properly designate a delegate
for the fiduciary's discretionary authority. Id. (citing Madden
v. ITT Long Term Disability Plan, 914 F.2d 1279, 1283-84 (9th Cir.
1990)).
In support of its assertions, Triple-S cites to language
from a section of the SPD titled "Statement of ERISA Rights," which
states that,
In addition to creating rights for plan participants,
ERISA imposes obligations upon the people who are
responsible for the operation of the plan. The people
who operate your plan[,] called "fiduciaries" of the
plan, have a duty to do so prudently and in the
interest of all plan participants and beneficiaries.
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This language, however, cannot be afforded the effect that Triple-S
attributes to it. It does not grant discretionary authority to
named fiduciaries, does not include Triple-S as a named fiduciary
under the Plan, and does not properly designate Triple-S as a
delegate for a fiduciary with discretionary authority. All this
language does is state that those who operate the Plan -- plan
fiduciaries -- have obligations under ERISA. The inclusion of
this statement in the SPD is even required by ERISA regulations.
See 29 C.F.R. 2520.102-3(t)(1) (stating that SPDs must include
"[t]he statement of ERISA rights described in section 104(c) of
the Act, containing the items of information applicable to the
plan included in the model statement of paragraph (t)(2) of this
section," which in turn includes the paragraph referenced by
Triple-S under the header "Prudent Actions by Plan Fiduciaries").
Thus, if this were enough to confer discretionary authority,
decisions under all regulations-compliant plans would be subject
to the deferential standard of review.
Finally, Triple-S posits that Rodríguez always "dealt
directly with Triple-S by filing all forms and pursuing all
available administrative review proceedings before it," which
supports a finding that Triple-S, and not Mova, had the authority
to make eligibility determinations. But these facts do not mean
that Triple-S was "clearly" delegated with discretionary
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authority. As we have noted, it just means that Triple-S had the
power to decide, but power to decide does not amount to the
existence of discretion. See Stephanie C., 813 F.3d at 428;
Rodríguez-Abreu, 986 F.2d at 584 (fact that plan administrator
denied benefits claim did not cure failure to delegate
discretionary authority, so denial reviewed de novo).
We hold that the Plan does not confer discretionary
authority upon Triple-S. Thus, de novo review applies. Because
the district court looked at Triple-S's denial of benefits through
the wrong standard-of-review lens, we must vacate its judgment and
remand for reconsideration.
III. Conclusion
For the reasons stated above, we vacate the judgment and
remand for further proceedings consistent with this opinion.5 No
costs are awarded.
Vacated and Remanded.
5 This may be an appropriate time for the parties to seriously
consider settlement.
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