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Santana-Diaz v. Metropolitan Life Insurance Co.

United States Court of Appeals, First Circuit

March 29, 2019

DIONISIO SANTANA-DÍAZ, Plaintiff, Appellant,
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., Defendants.

          APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF PUERTO RICO Hon. Aida M. Delgado-Colón, U.S. District Judge

          Efraín Maceira-Ortiz for appellant.

          Frank Gotay-Barquet, with whom Gotay & Pérez, P.S.C. was on brief, for appellee.

          Before Howard, Chief Judge, Thompson and Barron, Circuit Judges.

          HOWARD, CHIEF JUDGE

         This case concerns the denial of long-term disability ("LTD") benefits for Plaintiff-Appellant Dionisio Santana-Díaz ("Santana") under his employee welfare benefit plan ("Plan"). After the Plan's administrator, Defendant-Appellee 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"), 29 U.S.C. §§ 1001-1461. Applying the parties' agreed-upon standard of review, the district court granted judgment on the administrative record to MetLife. For the reasons discussed below, we AFFIRM.

         I.

         We begin with the basic facts leading to August 2011, when MetLife denied Santana's claim for LTD benefits under the Plan through his employer, Shell Chemical Yabucoa, Inc. 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, effective as of November 2008.

         Over the course of 2010 and 2011, Santana and MetLife exchanged a series of correspondence. MetLife sent Santana a letter in April 2010 informing him that his limited disability benefits would expire that November unless MetLife received objective medical information establishing that he was eligible for LTD benefits. In November 2010, MetLife sent Santana another letter, this time terminating his disability benefits on the ground that his disability was a limited-benefit condition.[1] MetLife further 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." The letter also advised Santana of his right to appeal the denial of benefits with MetLife, which he proceeded to do in April 2011. Santana explained 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 MetLife's August 19, 2011, letter denying Santana's claim ("MetLife's Final Decision"). MetLife's Final Decision shows that in early June 2011, the occupational medicine consultant spoke with Santana's primary care physician, Dr. Catoni. According to MetLife, "Dr. Catoni 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 noted that although Dr. Catoni stated this, the clinical data provided did not confirm the presence of lumbosacral neuropathy or any diabetic peripheral neuropathy. Furthermore, "the consultant indicated there were no physical exams, office visits, or any clinical findings provided in the records that supported that these conditions were causing any physical impairment." Consequently, the consultant concluded that the medical records did not support a limited benefit exclusionary diagnosis of radiculopathies or other enumerated conditions.

         On June 9, 2011, MetLife faxed a copy of the consultants' reports to Santana's doctors, requesting that they submit any comments on the reports. Dr. Catoni responded, expressing concern about the occupational medicine consultant's report, which stated that there was no evidence of diabetic polyneuropathy. He noted his office record from February 25, 2011, in which the condition was "well documented," and he accordingly sent additional records to MetLife. MetLife directed the occupational medicine consultant to review the file further, after which the consultant stated that "he still had no physical examinations, objective findings or office visit reports that supported that the diagnosis of diabetic peripheral neuropathy led to physical impairment and consequently restrictions and limitations on work abilities."

         Subsequently, MetLife's Final Decision letter denied Santana's claim. 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." Thus, in line with its consultant's findings, MetLife concluded that "the medical information provided is limited and does not support that any of these conditions alone or in combination would preclude [Santana] from performing [his] own sedentary job as an accountant."

         After exhausting the Plan's administrative remedies, Santana began this action on August 18, 2013, filing suit under ERISA, 29 U.S.C. § 1132(a)(1)(B), 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. In May 2014, MetLife moved for summary judgment. The district court granted summary judgment in MetLife's favor in January 2015, holding that the Plan's statute of limitations barred Santana's complaint. Santana appealed the district court's order, and, in March 2016, we reversed, holding that the contractual statute of limitations did not apply because MetLife failed to advise Santana of the deadline for seeking judicial review of its decision. Santana-Díaz v. Metro. Life Ins. Co., 816 F.3d 172 (1st Cir. 2016). In late 2016, back in the district court, the parties ...


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