Court Rules in Favor of MetLife: Clinical is Not An Ambiguous Term

Case Name: Santana-Diaz v. Metropolitan Life Insurance Company

Court: United States District Court for the District of Puerto Rico

Date of Decision: March 29, 2017

Type of Claim: Long Term Disability under the Employee Retirement Income Security Act of 1974(“ERISA”), as amended, 29 U.S.C. §§ 1001-1461.

Insurance Company: Metropolitan Life Insurance Company, aka MetLife for short.

Claimant’s Employer: Shell Chemical Yabucoa, Inc.

Claimant’s Occupation / Job Position: Accountant and Financial Analyst

Disabilities: Depression

Benefits Paid? Yes, for the first 24 months.

Basis For Denial / Termination of Benefits: By a letter, dated April 5, 2010, MetLife informed Santana that he was eligible for only twenty-four months of benefits based on his mental disorder (i.e., depression) diagnosis and that if he wanted to continue receiving benefits after November 2010, he needed to prove that his disorder stemmed from schizophrenia, bipolar disorder, dementia, or organic brain disease.

Procedural history: Santana then responded with a letter of his own, dated April 19, 2010, in which he claimed to suffer also from asthma, arthritis, hypertension, high cholesterol, and blood-sugar problems, and in which he vowed to undergo a full medical examination.

In a letter dated November 24, 2010, MetLife stated that Santana’s disability benefits had ended on November 22, 2010, and that the ailments recounted in Santana’s April 19, 2010 letter did not entitle him to further benefits because those ailments did not prevent him from returning to work. MetLife advised Santana that he could administratively appeal its termination of his benefits, but he would have to indicate why he disagreed with the termination and submit medical evidence in support of his claim for further benefits. By a letter, dated December 14, 2010, Santana appealed the termination. He submitted supporting medical evidence to MetLife, as requested. Some of the evidence diagnosed Santana with neuropathy, a degeneration of the nervous system, or with radiculopathy, an injury to a nerve.

Key Physician Opinions: MetLife forwarded responses from Santana’s treating physicians to Dr. Simon, an “independent physician”, who reviewed them and concluded that the MRI was normal for a person of Santana’s age and that Santana had still failed to submit clinical evidence showing that he had either radiculopathy or any limitations due to neuropathy. By a letter, dated August 19, 2011, MetLife denied Santana’s administrative appeal and upheld its earlier decision to deny him continuing long-term disability benefits.

Issue: Whether MetLife’s denial was reasoned and supported by substantial evidence.

Holdings: The Court finds that substantial evidence supports MetLife’s denial of continuing long-term disability benefits to Santana. Santana does not challenge that, under the Plan, he had the burden of establishing that he suffers from a disability that qualifies for such benefits. And, he admits that the independent physicians who reviewed his file, including the evidence he had submitted, found that the record contained insufficient clinical findings and data to sustain the conclusion that he suffered from a qualifying disability.

Other noteworthy court comments: As to the evidence allegedly showing that he suffers from radiculopathy, Santana points primarily to three items: 1) a 2010 electromyogram (“EMG”), 2) a February 25, 2011 progress note, and 3) an MRI from July 13, 2011. Although Santana refers to the EMG repeatedly in his motion, he does not identify whether or where the EMG appears in the record. … Now, even if those tests established that Santana suffered from polyneuropathy or another diagnosed condition, it would not detract from Dr. Simon’s finding that both tests, as well as the other evidence Santana had submitted, failed to prove that any of those conditions has caused him to experience “functional limitations.” And, if Santana does not suffer from such limitations, he is not “disabled” under the Plan.
…

Although the record shows that Santana’s personal doctors had diagnosed him with several disorders, “ERISA does not require plan administrators or reviewing courts to accord special deference to the opinions of treating physicians.” [Gannon v. Metro. Life Ins. Co., 360 F.3d 211, 215 (1st Cir. 2004)](citing Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003)). Under the terms of the Plan, it was within MetLife’s discretion to weigh that competing evidence to determine whether Santana was ‘disabled’ and hence whether he was entitled to continued benefits. “And in the presence of conflicting evidence, it is entirely appropriate for [the Court] to uphold the decision of the entity entitled to exercise its discretion.” Id. at 216.
…
Finally, Santana complains that MetLife did not define the kinds of “clinical” evidence it needed him and his physicians to produce to support his diagnoses. However, he fails to explain how the term “clinical” is ambiguous, and the Court does not see why it would be. Besides, the reports by MetLife’s independent physicians indicated the types of clinical evidence they needed to see. For example, Dr. Simon’s report begins by recounting the evidence in the record supporting Santana’s diagnoses, which appears to have been largely comprised of doctors’ notes and reports about images and exams that may not have been part of the record themselves. When asked about the “specific, clinical findings/data” that support Santana’s claims, Dr. Simon states there are none. When asked why the record lacks such evidence, he adds that, though there are documents asserting that Santana has certain diagnoses, there is “no corroborating information to support th[e] diagnos[e]s (i.e. there are no MRI, CT or plain X-ray films . . . to support th[e] assertion.).” Moreover, there were no recent medical reports establishing that Santana had “any functional limitations due to [a diagnosed condition].” Thus, it is clear what MetLife meant by “clinical” evidence. In any event, Santana fails to explain how he was prejudiced by any ambiguity in that term, nor does he allege that he even misinterpreted the term due to ambiguity.

Summary: The Court agrees with MetLife that, under circuit precedent, these record-based “findings by [the] independent medical examiner[s] g[i]ve MetLife the requisite ‘substantial evidentiary grounds for a reasonable decision in its favor.’”