The case of Dionisio Santana-Diaz v. Metropolitan Life Insurance Company (MetLife) demonstrates how important it is for claimants to present as much medical evidence as possible to the plan administrator who is evaluating the claim for Long Term Disability (LTD) benefits. Despite many opportunities to do so during the initial evaluation and subsequent administrative appeal, Santana failed to provide the requested medical documentation to support his claim.
After working for 25 years as an accountant for Shell Chemical Yabucoa, Inc., Santana’s request for LTD benefits due to a mental disorder and depression was approved. Met-Life paid him benefits for the Plans limited 24-month benefit duration period for mental health disorders beginning in November 2008.
In April 2010, MetLife sent a letter to Santana telling him his benefits would be terminated in November 2010 unless he provided objective medical evidence establishing that he was eligible for LTD benefits on a basis that was not due to a mental disorder. Santana did not respond. As a result, in November 2010, he received a letter from MetLife telling him his benefits had been terminated. He was also informed he had the right to appeal.
The Administrative Appeal: Santana Failed to Present Evidence to Support His Claim
Early in the appeal process, MetLife’s hired physician reviewer consulted with Santana’s primary care physician, Dr.Catoni, who at first said that Santana’s primary problem was psychological. Catoni then added that Santana had been diagnosed with peripheral neuropathy and could not walk long distances and could not raise his arms far above his head due to arthritis in his shoulders. Dr. Catoni did not give an opinion on how these conditions would prevent Santana from doing his job.
MetLife’s reviewing physician then reported that he did not find any objective evidence in the medical file to support either one of these diagnoses. There was no evidence of any physical exam documenting them, no office visits, and no test results. There was nothing in the record to even suggest how these conditions would impair Santana’s ability to work as an accountant.
MetLife faxed this report to Dr.Catoni. Dr. Catoni responded by drawing attention to an office note from February 25, 2011, in which he contended that the diagnosis of peripheral neuropathy was well-documented. The note was simply Dr. Catoni’s conclusion that Santana suffered from diabetic peripheral neuropathy. The doctor sent additional medical records to MetLife.
The additional medical records did not contain any additional documentation of test results or objective evidence supporting the diagnosis of diabetic peripheral neuropathy, or any evidence about how that diagnosis led to any physical impairment or restrictions and limitations on work abilities. Therefore, MetLife upheld its previous termination of benefits. Santiago then filed an ERISA lawsuit.
ERISA Lawsuit: Court is Limited to Review of Administrative Record and Will Not Consider Any New Evidence
When federal district courts are faced with an ERISA lawsuit, they are legally bound to consider only the evidence in the administrative record that was before the Plan administrator when the decision was made. The Court will not consider any new medical tests, any new notes from doctor’s office visits, any testimony from anyone, including doctors or employers.
Since Santana had not presented the requested evidence during the appeal to MetLife, so there was no documentation of the diagnosis of diabetic peripheral neuropathy other than Dr. Catoni’s opinion, and he presented no evidence of how that condition would impair his ability to work, the Court was essentially hamstrung. It almost had no choice but to uphold the decision by MetLife.
Contrary to Santana’s Assertion, MetLife Informed Him of Evidence It Required, But He Failed to Provide It
The federal district court initially determined Santana had failed to prove by a preponderance of the evidence that he was entitled to LTD benefits, and that decision was upheld by the United States Court of Appeals for the First Circuit. MetLife had informed Santana that he had to prove:
1) That he had a qualifying condition; and
2) That the condition caused him to be disabled under the plan.
Since Santana repeatedly failed to provide the Plan that evidence, the Courts decided that he had not met his burden of proving by a preponderance of the evidence that he suffered from a qualifying condition, and that that condition prevented him from performing the duties of an accountant. Therefore, he was not entitled to LTD benefits.
This case was not handled by our firm. If you have experienced a denial of LTD benefits, or benefits you were receiving have been terminated, we urge you to contact one of our attorneys at Dell & Schaefer. We offer a free consultation where we will review your case and determine what evidence needs to be submitted for your administrative appeal that will give you the best chance of winning your LTD benefits. There are no guarantees in the law, but we work to provide as much evidence as possible to support your appeal and to comply with all evidentiary requirements of your disability insurance company.