FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF
PUERTO RICO Hon. Aida M. Delgado-Colón, U.S. District
Efraín Maceira-Ortiz for appellant.
Gotay-Barquet, with whom Gotay & Pérez, P.S.C. was
on brief, for appellee.
Howard, Chief Judge, Thompson and Barron, Circuit Judges.
HOWARD, CHIEF JUDGE
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.
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.
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. 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
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.
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
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
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 ...