{"id":7578,"date":"2020-06-29T21:02:00","date_gmt":"2020-06-30T02:02:00","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7578"},"modified":"2024-01-11T17:24:32","modified_gmt":"2024-01-11T22:24:32","slug":"santana-diaz-v-metlife-court-rules-clinical-is-not-an-ambiguous-term","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/santana-diaz-v-metlife-court-rules-clinical-is-not-an-ambiguous-term\/","title":{"rendered":"Santana-Diaz v. MetLife – Court Rules Clinical is Not An Ambiguous Term"},"content":{"rendered":"

Case Name:\u00a0<\/strong>Santana-Diaz v. Metropolitan Life Insurance Company<\/p>\n

Court:\u00a0<\/strong>United States District Court for the District of Puerto Rico<\/p>\n

Date of Decision:\u00a0<\/strong>March 29, 2017<\/p>\n

Type of Claim:\u00a0<\/strong>Long-term disability<\/a> under the\u00a0Employee Retirement Income Security Act of 1974 (\u201cERISA\u201d), as amended, 29 U.S.C. \u00a7\u00a7 1001-1461.<\/p>\n

Insurance Company:\u00a0<\/strong>Metropolitan Life Insurance Company (MetLife)<\/a><\/p>\n

Claimant\u2019s Employer:\u00a0<\/strong>Shell Chemical Yabucoa, Inc.<\/p>\n

Claimant\u2019s Occupation \/ Job Position:\u00a0<\/strong>Accountant and Financial Analyst<\/a><\/p>\n

Disabilities:\u00a0<\/strong>Depression<\/a><\/p>\n

Benefits Paid?\u00a0<\/strong>Yes, for the first 24 months.<\/p>\n

Basis For Denial \/ Termination of Benefits:\u00a0<\/strong>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<\/a> (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<\/a>,\u00a0bipolar disorder<\/a>, dementia<\/a>, or organic brain disease<\/a>.<\/p>\n

Procedural history:\u00a0<\/strong>Santana then responded with a letter of his own, dated April 19, 2010, in which he claimed to suffer also from asthma,<\/a> arthritis<\/a>, hypertension<\/a>, high cholesterol, and blood-sugar problems, and in which he vowed to undergo a full medical examination.<\/p>\n

In a letter dated November 24, 2010, MetLife stated that Santana\u2019s disability benefits had ended on November 22, 2010 and that the ailments recounted in Santana\u2019s 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 supporting his claim for further benefits. In 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>, a degeneration of the nervous system, or with radiculopathy, an injury to a nerve.<\/p>\n

Key Physician Opinions:\u00a0<\/strong>MetLife forwarded responses from Santana\u2019s treating physicians to Dr. Simon, an \u201cindependent physician<\/a>,\u201d\u00a0who reviewed them and concluded that the MRI was normal for a person of Santana\u2019s 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\u2019s administrative appeal and upheld its earlier decision to deny him continuing long-term disability benefits.<\/p>\n

Issue:\u00a0<\/strong>Whether MetLife\u2019s denial was reasoned and supported by substantial evidence.<\/p>\n

Holdings:\u00a0<\/strong>The Court finds that substantial evidence supports MetLife\u2019s 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. 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.<\/p>\n

Other noteworthy court comments:\u00a0<\/strong>As to the evidence allegedly showing that he suffers from radiculopathy, Santana points primarily to three items: 1) a 2010 electromyogram (\u201cEMG\u201d), 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. \u2026 Now, even if those tests established that Santana suffered from polyneuropathy or another diagnosed condition, it would not detract from Dr. Simon\u2019s 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 \u201cfunctional limitations.\u201d And, if Santana does not suffer from such limitations, he is not \u201cdisabled\u201d under the Plan.
\n\u2026<\/p>\n

Although the record shows that Santana\u2019s doctors had diagnosed him with several disorders, \u201cERISA does not require plan administrators or reviewing courts to accord special deference to the opinions of treating physicians.\u201d [Gannon v. Metro. Life Ins. Co.<\/em>, 360 F.3d 211, 215 (1st Cir. 2004)](citing Black & Decker Disability Plan v. Nord<\/em>, 538 U.S. 822 (2003)). Under the terms of the Plan, it was within MetLife\u2019s discretion to weigh that competing evidence to determine whether Santana was \u2018disabled\u2019 and, hence, whether he was entitled to continued benefits. \u201cAnd 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.\u201d Id<\/em>. at 216.
\n\u2026
\nFinally, Santana complains that MetLife did not define the kinds of \u201cclinical\u201d evidence it needed him and his physicians to produce to support his diagnoses. However, he fails to explain how the term \u201cclinical\u201d is ambiguous, and the Court does not see why it would be. Besides, the reports by MetLife\u2019s independent physicians indicated the types of clinical evidence they needed to see. For example, Dr. Simon\u2019s report begins by recounting the evidence in the record supporting Santana\u2019s diagnoses, which appears to have been largely comprised of doctors\u2019 notes and reports about images and exams that may not have been part of the record themselves. Dr. Simon states there are none when asked about the \u201cspecific, clinical findings\/data\u201d that support Santana\u2019s claims. When asked why the record lacks such evidence, he adds that, though there are documents asserting that Santana has certain diagnoses, there is \u201cno corroborating information to support the diagnoses (i.e., there are no MRI, CT or plain X-ray films . . . to support the assertion.).\u201d Moreover, no recent medical reports established that Santana had \u201cany functional limitations due to [a diagnosed condition].\u201d Thus, it is clear what MetLife meant by \u201cclinical\u201d evidence. In any event, Santana fails to explain how any ambiguity in that term prejudiced him, nor does he allege that he even misinterpreted the term due to ambiguity.<\/p>\n

Summary:\u00a0<\/strong>The Court agrees with MetLife that, under circuit precedent, these record-based \u201cfindings by [the] independent medical examiners give MetLife the requisite \u2018substantial evidentiary grounds for a reasonable decision in its favor.\u2019\u201d<\/p>\n

Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.<\/div>\n
\n

Here is a PDF copy of the decision: Santana-Diaz v. MetLife<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

MetLife forwarded responses from Santana\u2019s treating physicians to Dr. Simon, an \u201cindependent physician,\u201d\u00a0who reviewed them and concluded that the MRI was normal for a person of Santana\u2019s 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\u2019s administrative appeal and upheld its earlier decision to deny him continuing long-term disability benefits. The Court agreed with MetLife that.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[258],"_links":{"self":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7578"}],"collection":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/comments?post=7578"}],"version-history":[{"count":0,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7578\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/media?parent=7578"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/categories?post=7578"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/tags?post=7578"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}