Hernandez-Medina v. Triple-S Vida, Inc., Civil No. 11-1776 (GAG)

LUCIA HERNANDEZ-MEDINA, Plaintiff,

v.TRIPLE-S VIDA, INC., Defendant.

Civil No. 11-1776 (GAG)

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF PUERTO RICO

Date: November 30, 2012

OPINION AND ORDER

Plaintiff Lucia Hernandez-Medina ("Plaintiff") filed the instant complaint against Triple-S Vida, Inc. ("Triple S") under the Employment Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001. Specifically, Plaintiff brings this action pursuant to 29. U.S.C. § 1132(a)(1), challenging the denial of long term disability ("LTD") benefits under a group policy issued by Triple S to Doral Bank ("Doral"), Plaintiff's former employer.

After reviewing the facts of the case, the court concludes that summary judgment for Triple S is warranted as a matter of law. Accordingly, the Court GRANTS Triple S's motion for summary judgment. (Docket No. 25)

I. PROCEDURAL AND FACTUAL HISTORY

Plaintiff was Branch Manager at Doral. (See Docket No. 27 at 8.) Plaintiff had disability insurance coverage under Doral's Long Term Disability Insurance Plan (the "Plan"). (See Docket No. 25 at 5.) The Plan is governed by ERISA and administered byTriple S. (See Docket No. 27 at 4.)

On March 10, 2010, Triple S informed Plaintiff she was not eligible for LTD benefits under Doral's policy based on the information provided to date. (See Docket No. 26 at 8, ¶ 24.) Plaintiff appealed this decision on May 4, 2010. (See Docket No. 26 at 8, ¶ 29.) Triple S informed Plaintiff she could submit additional information for review. (See Docket No. 26 at 9, ¶ 31.)

Triple S asked Dr. Sergio Loaiza to review Plaintiff's record as it pertained to her ability to perform her job. (See Docket No. 26 at 9, ¶ 32.) After reviewing Plaintiff's record, Dr. Loaiza stated that no functional physical disability existed from the date on which Hernández claimed disability, April 28, 2009. (See Docket No. 25 at 8.)

Another independent review of Plaintiff's records was conducted by Dr. Joseph Gonzalez-Heydrich. Dr. Gonzalez-Heydrich opined that the records do not adequately document a psychological disability from April 28, 2009 to October 25, 2009 or anytime thereafter. (See Docket No. 25 at 9.)

On May 4, 2010, Plaintiff appealed Triple S's decision to deny her LTD benefits and sent Triple S additional medical information. (See Docket No. 25 at 8.) Triple S informed Plaintiff that additional medical review was warranted and referred her file for review by independent medical specialists. (See Docket No. 25 at 8-9.)

On July 14, 2010, Triple S denied Plaintiff's appeal, reiterating its decision to deny her application for disability benefits. (See Docket No. 26 at 35, ¶ 81.) Triple S determined Plaintiff was not eligible to receive LTD benefits due to the lack of clinical evidence to support a psychiatric or physical condition resulting in her inability to perform the essential duties of her position. (See Docket No. 26 at 35, ¶ 82.)

Plaintiff filed the present complaint on July 5, 2011. (See Docket No. 1-2.) Plaintiff claims that the denial of LTD benefits for physical illness is unreasonable, arbitrary, and capricious. Plaintiff further contends that Triple S's dual role as plan administrator and insurer constitutes a conflict of interests.

Defendant filed a notice of removal from state court to federal court on August 8, 2011. (Docket No. 1.) On July 2, 2012, Triple S filed its Motion for Summary Judgment (Docket No. 25) and corresponding Statement of Uncontested Material Facts (Docket No. 26). Plaintiff filed her Motion for Summary Judgment (Docket No. 27) and Statement of Uncontested Material Facts (Docket No. 28) on July 19, 2012. A Response in Opposition to Plaintiff's Motion for Summary Judgment (Docket No. 32) and Surreply to Defendant's Reply to Plaintiff's Response to Motion for Summary Judgment (Docket No. 33) were subsequently filed by Triple S and Plaintiff, respectively.

II. SUMMARY JUDGMENT

Summary judgment is appropriate when "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." FED. R. CIV. P. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). "An issue is genuine if 'it may reasonably be resolved in favor of either party' at trial, and material if it 'possess[es] the capacity to sway the outcome of the litigation under the applicable law.'" Iverson v. City of Boston, 452 F.3d 94, 98 (1st Cir. 2006) (alteration in original) (citations omitted). The moving party bears the initial burden of demonstrating the lack of evidence to support the non-moving party's case. Celotex, 477 U.S. at 325. "The movant must aver an absence of evidence to support the nonmoving party's case. The burden then shifts to the nonmovant to establish the existence of at least one fact issue which is both genuine and material." Maldonado-Denis v. Castillo-Rodriguez, 23 F.3d 576, 581 (1st Cir. 1994). The nonmoving party must then "set forth specific facts showing that there is a genuine issue for trial." FED. R. CIV. P. 56(e). If the court finds that some genuine factual issue remains, the resolution of which could affect the outcome of the case, then the court must deny summary judgment. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986).

When considering a motion for summary judgment, the court must view theevidence in the light most favorable to the non-moving party and give that party the benefit of any and all reasonable inferences. Id. at 255. Moreover, at the summary judgment stage, the court does not make credibility determinations or weigh the evidence. Id. Summary judgment may be appropriate, however, if the non-moving party's case rests merely upon "conclusory allegations, improbable inferences, and unsupported speculation." Forestier Fradera v. Mun. of Mayaguez, 440 F.3d 17, 21 (1st Cir. 2006) (quoting Benoit v. Technical Mfg. Corp., 331 F.3d 166, 173 (1st Cir. 2003)).

"Cross-motions for summary judgment do not alter the summary judgment standard, but instead simply require [the court] to determine whether either of the parties deserves judgment as a matter of law on the facts that are not disputed." Wells Real Estate Inv. Trust II, Inc. v. Chardon/Hato Rey P'ship, S.E., 615 F.3d 45, 51 (1st Cir. 2010) (citing Adria Int'l Group, Inc. v. Ferré Dev. Inc., 241 F.3d 103, 107 (1st Cir. 2001)) (internal quotation marks omitted). Although each motion for summary judgment must be decided on its own merits, each motion need not be considered in a vacuum. Wells Real Estate Inv. Trust II, Inc., 615 F.3d at 51 (quoting P.R. Am. Ins. Co. v. Rivera-Vázquez, 603 F.3d 125, 133 (1st Cir. 2010)) (internal quotation marks omitted). "Where, as here, cross-motions for summary judgment are filed simultaneously, or nearly so, the district court ordinarily should consider the two motions at the same time, applying the same standards to each motion." Wells Real Estate Inv. Trust II, Inc., 615 F.3d at 51 (quoting P.R. Am. Ins. Co. v. Rivera-Vázquez, 603 F.3d 125, 133 (1st Cir. 2010)) (internal quotation marks omitted).

III. DENIAL OF BENEFITS CLAIM

Under ERISA's civil enforcement provision, 29 U.S.C. § 1132(a)(1)(B), judicial review of a benefit entitlement decision may be the subject of two separate standards. Eusebio Cotto Villegas v. Fed. Express Corp., 468 F.Supp. 2d 293, 306 (D.P.R. 2006). If the plan "gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan," then the court must apply the deferential "arbitrary and capricious" standard of review. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Leahy v. Raytheon Co., 315 F.3d 11, 15 (1st Cir. 2002). The arbitrary and capricious standard applies if a reading of the plan in question indicates a clear grant of discretionary authority to the administrator in determining the eligibility for benefits of a participant or beneficiary. See Terry v. Bayer Corp., 145 F.3d 28, 37 (1st Cir. 1998). "This standard means that the administrator's decision will be upheld if it is reasoned and supported by substantial evidence in the record." Doyle v. Paul Revere Life Ins. Co., 144 F.3d 181, 184 (1st Cir. 1998) (quoting Assoc. Fisheries of Maine, Inc. v. Daley, 127 F.3d 104, 109 (1st Cir. 1997)); see Vlass v. Raytheon Employees Disability Trust, 244 F.3d 27, 30 (1st Cir. 2001). "Evidence is 'substantial' if it is reasonably sufficient to support a conclusion." Vlass, 244 F.3d at 30 (citations omitted). "Moreover, the existence of contradictory evidence does not, in itself, make the administrator's decision arbitrary." Id. (citations omitted). Where such clear grant of discretionary authority is not apparent, the standard of reviewis de novo. Firestone Tire & Rubber Co., 489 U.S. at 115; see also Rodriguez-Abreu v. Chase Manhattan Bank, N.A., 986 F.2d 580, 583 (1st Cir. 1993).

Furthermore, the First Circuit has held "that a conflict of interest does not change the standard of review from deferential to de novo." Diaz v. Metropolitan Life Ins. Co., 688 F. Supp. 2d 49, 60 (D.P.R. 2010) (citing Cusson v. Liberty Life Assur. Co. of Boston, 592 F.3d 215, 224 (1st Cir. 2010)). The fact that an administrator both determines benefits entitlements and pays out the benefits does not present such a serious conflict of interest. Sanchez-Figueroa v. Seguros de Vida Triple S, Inc., 2006 WL 2847385 at *11 (D.P.R. Sep. 29, 2006) (citing Doyle, 144 F.3d at 184). In situations where the conflict of interest is purely structural, i.e., when the insurer of an ERISA plan also serves as plan administrator-courts "must apply arbitrary and capricious review." Denmark, 481 F.3d at 31. "[S]pecial emphasis should be paid on reasonableness . . . with the burden on the claimant to show that the decision was improperly motivated." Sanchez-Figueroa, 2006 WL 2847385 at *11 (quoting Doyle, 144 F.3d...