Medina v. Metropolitan Life Insurance, (1st Cir. 2009)

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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

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

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

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

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.

         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 &

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

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

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

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

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

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

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.

Footnotes

[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

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.

[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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