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

United States Court of Appeals, First Circuit

March 1, 2017

NILDA RODRIGUEZ-LOPEZ, 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]

          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.

          Before Torruella, Thompson, and Kayatta, Circuit Judges.

          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 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 fulltime 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, 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 TripleS. 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 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 ...


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