Diaz v. Metropolitan Life Ins. Co.

688 F.Supp.2d 49

Nancy DIAZ, et al., Plaintiffs, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

Civil No. 07-1564 (FAB).

United States District Court, D. Puerto Rico.

March 2, 2010.

Pedro J. Landrau-Lopez, San Juan, PR, for Plaintiffs.

Frank Gotay-Barquet, Gotay & Perez, P.S.C., San Juan, PR, for Defendant.

OPINION & ORDER

BESOSA, District Judge.

Plaintiffs Nancy Diaz ("Diaz"), Felix Diaz-Perez ("Diaz-Perez"), and their conjugal partnership (collectively referred to as "plaintiffs") bring this action pursuant to Section 502 of the Employee Retirement Income Security Act ("ERISA").¹ The plaintiffs claim that Citi Group, Inc.'s Long Term Disability Plan ("LTD") is administered by defendant Metropolitan Life Insurance Company ("MetLife"), and that MetLife denied plaintiff Diaz the disability benefits due to her under the LTD.

On February 4, 2008, plaintiffs moved for judgment on the administrative record (Docket No. 12). MetLife filed its opposition and cross-motion for judgment on the administrative record on March 18, 2008. (Docket No. 17)

For the reasons provided below, the Court GRANTS MetLife's motion for judgment on the administrative record and DENIES plaintiffs' motion for judgment on the administrative record.

I. Background²

Relevant facts are culled from the parties statements of facts, which both refer to the administrative record. Additional facts may be added when necessary in the analysis section. The Court relies on the Administrative Record³ and the Summary Plan Description⁴ ("SPD"). Morales-Alejandro, 486 F.3d 693, 698 (1st Cir.2007) ("ERISA cases are generally decided on the administrative record without discovery, and `some very good reason is needed to overcome the presumption that the record on review is limited to the record before the administrator'") (quoting Liston v. Unum Corp. Officer Severance Plan, 330 F.3d 19, 23 (1st Cir.2003)).

A note about the Court's review of the administrative record. The administrative record on file in this case contains documents in their original Spanish language form without accompanying translations and handwritten documents which are either totally or partially illegible. The parties filed their motions and supporting documents for their cross motions for judgment on the administrative record in 2007, the administrative record filed contains some documents in the Spanish language that were not accompanied by certified English translations as they are now required to be. See Dalmau, 544 F.3d 58. Federal law requires that "all and proceedings in the United States District Court for the District of Puerto Rico shall be conducted in the English language." Puerto Ricans for P.R. Party v. Dalmau, 544 F.3d 58, 67 (1st Cir.2008). There was no need to request translations of the few Spanish-language documents in the administrative record for reasons this Court wishes to express for the sake of transparency and the record.

Most significantly, the parties in this case do not dispute the content of the administrative record (except for the content of the SPD, which is in English and readily accessible to the Court); they dispute whether the decision reached by the defendant was refer to the contents of a Spanish-language diagnosis or progress report by a doctor, the parties refer to those contents of those documents not to dispute the contents themselves, but to dispute the manner in which MetLife treated the content in its review of Diaz's claim for disability benefits. As another example, MetLife argues that there are inconsistencies in the record regarding the dates that Diaz received treatment for her claimed condition. In making this argument, MetLife points out the manner in which dates of treatment do not remain consistent on the various documents in Diaz's medical file, something it considered when rendering its decision to deny Diaz benefits. Again, the parties do not dispute the content contained in the documents (the dates of treatment as listed or claimed in each document), only whether the inferences that Metlife drew from those documents were reasonable. Stated plainly, the untranslated documents in the Administrative Record are not material to the Court's review in this case because the questions presented to the Court are legal, not factual in nature.

A. Plaintiff Nancy Lillian Diaz

Diaz, a female born in 1958, worked as an Operations Manager of CitiBank's Financial Center from 1979 through April 22, 2004 (AR at 189-90). Long term disability benefits are provided to eligible employees through CitiBank's Long Term Disability Plan ("LTDP"), a group policy issued by MetLife. While working for CitiBank, Diaz was a "Class I" participant of the LTDP.⁵

B. CitiBank's Long Term Disability Plan

Citibank is the Plan Administrator⁶ of the LTDP, as listed in the SPD's ERISA Information section (SPD at 47).⁷ MetLife is a plan fiduciary "because it has authority to determine eligibility for benefits under the Plan and to review denied claims." (Docket No. 17 at 8) (citing, inter alia, Libbey-Owens-Ford Co. v. Blue Cross & Blue Shield Mut. of Ohio, 982 F.2d 1031, 1035 (6th Cir.1993)) (claims administrator was ERISA fiduciary because "it retained authority to resolve all disputes regarding coverage"). According to the SPD's ERISA Information section, "the Plan administrator and other Plan fiduciaries shall have discretionary authority to interpret the terms of the Plan to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan." (SPD at 50.) The SPD states that "any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious." Id. The SPD identifies MetLife as having discretionary authority "to interpret the terms, conditions, and provisions of the entire contract" including "the Group Policy, Certificate and any Amendments" (SPD at 3). The SPD also explains that "Reference to `we,' `us' or `our' means MetLife," and directs employees to direct all disputes, questions, and legal actions to MetLife. Id.

The SPD contains the many details of long term disability benefits coverage. Employees do not qualify for monthly benefits under the LTDP unless they are disabled and become disabled while covered under the LTDP. Id. at 21. The SPD defines terms such as "disability", "Appropriate Care and Treatment", and "Doctor", and sets forth specific procedures in the event that an employee claims long term disability benefits.

The SPD provides for a 90-day "Elimination Period" during which no long term disability benefits are paid, although the employee may receive short term disability benefits. Id. at 16, 23. The claimant must be totally disabled and under a doctor's regular care during the elimination period. Id. According to the SPD:

If you are a member of Class I, "Disabled" or "Disability" means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis and

1. During the Elimination Period you are Totally Disabled;

"Totally Disabled" or "Total Disability" means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis, and during your Elimination Period, you are unable to perform your Own Occupation for any employers in your Local Economy.

2. After your Elimination Period and during the next 24 month period, you are unable to earn more than 80% of your Predisability Earnings at your Own Occupation for any employer in your Local Economy; or

3. after the 24 months period, you are unable to earn more than 60% of your Predisability Earnings from any employer in your Local Economy at any gainful occupation for which you are reasonable sic qualified taking into account your training, education, experience and Predisability Earnings.

(SPD at 23) (internal quotations in original)(all capitalized terms refer to terms used and defined elsewhere in the SPD).

The SPD defines the term "Appropriate Care and Treatment" as follows:

1. It is received from a Doctor whose medical training and clinical experience are suitable for treating your Disability;

2. It is necessary to meet your health needs and is of demonstrable medical value:

3. It is consistent in type, frequency and duration of treatment with relevant guidelines of national medical, research and health care coverage organizations and government agencies.

4. It is consistent with the diagnosis of your condition; and

5. Its purpose is maximizing your medical improvement.

SPD at 24. The SPD defines "Own Occupation" as:

The activity that you regularly perform and that serves as your source of income. It is not limited to the specific position you held with your Employer. It may be a similar activity that could be performed with your Employer or any other employer.

Id. at 25. Monthly benefits are limited to twenty-four months during the claimant's lifetime for disability due to mental or nervous disorders or diseases. (SPD at 33.) The SPD defines "Mental or Nervous Disorder or Disease" as "a mental condition which meets the diagnostic criteria set forth in the most recent edition of the Diagnostic And Statistical Manual Of Mental Disorders as of the Date of your Disability." Id. (capitalization as found in original).

To receive benefits, the eligible employee must notify MetLife of the disability as soon as able, provide MetLife certain documents and fill out certain forms at his or her own expense, in addition to other related materials requested by MetLife. Id. at 17. Among the requirements MetLife demands of eligible employees for its determination of whether the employee is due benefits is "proof that you applied for Social Security disability benefits until denied at the Administrative Law Judge Level." Id. at 37. MetLife provides assistance to...