ERISA Administrator’s Decision Affirmed

Decision of ERISA will not be Reversed if Supported by the Evidence

Long Term Disability Claims under an ERISA plan can be appealed to federal courts who can set aside the decision of the ERISA plan administrator only if it is not supported by adequate evidence.

In Dionisio Santana-Díaz 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., No. 17-1428, United States Court of Appeals For the First Circuit (March 29, 2019) Long-term disability (“LTD”) benefits were denied to Dionisio Santana-Díaz (“Santana”) under his employee welfare benefit plan (“Plan”). After the Plan’s administrator 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”). The district court granted judgment on the administrative record to MetLife. Santana-Diaz appealed to the First Circuit.

FACTS

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.

MetLife before the expiration of the limited benefit  advised him that his limited disability benefits would expire that November unless MetLife received objective medical information establishing that he was eligible for LTD benefits. MetLife concluding he was not eligible sent Santana a letter terminating his disability benefits on the ground that his disability was a limited-benefit condition. MetLife 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.”

Santana claimed 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 the denial of Santana’s claim (“MetLife’s Final Decision”). The occupational medicine consultant spoke with Santana’s primary care physician, Dr. Catoni who 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 concluded that the medical records did not support a limited benefit exclusionary diagnosis of radiculopathies or other enumerated conditions.

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.”

After exhausting the Plan’s administrative remedies, Santana sued under ERISA 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. MetLife moved for summary judgment. The district court found that MetLife acted reasonably, and thus granted MetLife’s motion.

ANALYSIS

To reverse the First Circuit must determine whether MetLife’s denial of Santana’s LTD benefits was arbitrary, capricious or an abuse of discretion. In such plans, the employer (or an insurance company that stands in the employer’s shoes) must spell out exclusions distinctly.

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. A plan administrator’s decision must be reasoned and supported by substantial evidence. If the plan administrator’s interpretation of the plan is reasonable, then it will not be disturbed.

Santana chiefly argued that the Plan Administrator’s denial of LTD benefits was arbitrary and capricious because the administrator cherry-picked evidence it preferred while ignoring significant contrary evidence.

The U.S. 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.”

Santana concluded 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.

MetLife’s conclusion that these records failed to show that Santana was physically disabled under the Plan is reasonably supported by the record and the First Circuit concluded was not arbitrary or capricious cherry-picking.

Santana also asserted that MetLife also acted arbitrarily by treating medical evidence inconsistently. From the 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 LTD benefits.

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 provide the required objective evidence. When 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.

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.

ZALMA OPINION

ERISA statutes give broad discretion to the plan administrator. Courts will affirm the plan administrator’s decision as long as there was a reasonably thorough claims process that was based on, or on the lack of, objective evidence of an entitlement to LTD benefits. Santana failed to provide the objective evidence to the plan administrator and, as a result, was properly denied the LTD benefits.


© 2019 – Barry Zalma

This article, and all of the blog posts on this site, digest and summarize cases published by courts of the various states and the United States.  The court decisions have been modified from the actual language of the court decisions, were condensed for ease of reading, and convey the opinions of the author regarding each case.

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant  specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 50 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.

Over the last 51 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

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About Barry Zalma

An insurance coverage and claims handling author, consultant and expert witness with more than 48 years of practical and court room experience.
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