Digregorio v. Hartford Comprehensive Emp. Ben.

• Decision Date: 08 September 2005
• Docket Number: No. 04-2219.,No. 04-2252.,04-2219.,04-2252.
• Citation: 423 F.3d 6
• Parties: Angela DiGREGORIO, Plaintiff, Appellant, v. HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE COMPANY; Pricewaterhousecoopers Long Term Disability Plan, Defendants, Appellees.
• Court: U.S. Court of Appeals — First Circuit

423 F.3d 6

Angela DiGREGORIO, Plaintiff, Appellant, v. HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE COMPANY; Pricewaterhousecoopers Long Term Disability Plan, Defendants, Appellees.

No. 04-2219.

No. 04-2252.

United States Court of Appeals, First Circuit.

Heard April 7, 2005.

Decided September 8, 2005.

COPYRIGHT MATERIAL OMITTED

Stephen L. Raymond, for appellant.

David B. Crevier, with whom Theodore F. Glockner was on brief, for appellees.

Before TORRUELLA, LIPEZ, and HOWARD, Circuit Judges.

LIPEZ, Circuit Judge.

Plaintiff-appellant Angela DiGregorio appeals the district court's judgment in favor of defendants-appellees Hartford Comprehensive Employee Benefit Service Company ("Hartford") and PricewaterhouseCoopers Long Term Disability Plan ("the Plan") on her claim of entitlement to long-term disability ("LTD") benefits under the Employee Retirement Income Security Act of 1974, 29 U.S.C § 1001-1461, as amended ("ERISA"). DiGregorio challenges only the district court's denial of her alternate prayer for relief requesting a remand to Hartford, the Plan administrator, for supplementation of the administrative record, on the ground that Hartford and the Plan failed to provide a reasonable opportunity for full and fair review of her benefits claim in violation of ERISA § 503, 29 U.S.C. § 1133, and its implementing regulations. Because the district court did not err in determining that a remand was unwarranted on the facts of this case, we affirm the district court's judgment.¹

I.

The facts of this case are set forth in detail in the district court's opinion. See DiGregorio v. Pricewaterhouse Coopers Long Term Disability Plan, No. 03-11191, 2004 WL 1774566 2004 U.S. Dist. LEXIS 15485 (D.Mass. Aug. 9, 2004). We relate only those facts, undisputed unless otherwise noted, that are relevant to this appeal.

A. DiGregorio's Claim for LTD Benefits

DiGregorio worked as a secretary for Coopers & Lybrand (now PricewaterhouseCoopers) from September 1988 through early February 1995, when she began receiving worker's compensation. In July 1995, DiGregorio applied for LTD benefits under the Coopers & Lybrand Employee Long Term Disability and Income Plan, now the PricewaterhouseCoopers Long Term Disability Plan. In support of her claim, she submitted a statement by her attending physician, Dr. Walsh, diagnosing DiGregorio with bilateral carpal tunnel syndrome that totally disabled her from performing her job as a secretary. The Plan administrator, then the Pacific Mutual Life Insurance Company, approved DiGregorio's claim in September 1995, and DiGregorio began receiving LTD benefits for the period beginning August 1, 1995.

Under the terms of the Plan, DiGregorio was entitled to LTD benefits for "Total Disability" for a period of up to two years so long as she could "perform no duty pertaining to [her] occupation" as a secretary. DiGregorio was entitled to continue receiving benefits beyond the two-year period only so long as she could "perform no duty pertaining not only to [her] occupation but to any occupation... for which [she] is, or may be, qualified by education, training or expertise" (emphasis added). DiGregorio continued to receive LTD benefits beyond the initial two-year period.

B. Hartford's Termination of DiGregorio's LTD Benefits

In July 1999, PricewaterhouseCoopers retained Hartford to administer claims for benefits under the Plan. In August 1999, at Hartford's request, DiGregorio completed an "Authorization to Obtain and Release Information" permitting Hartford to periodically obtain DiGregorio's updated medical information so that Hartford could verify her disability status and eligibility for benefits.

On April 18, 2001, Hartford notified DiGregorio by letter that "the evidence submitted in support of your claim does not establish that you meet the Plan definition of Total Disability on or after April 16, 2001." Hartford stated that it had based its "decision to deny your claim for benefits upon Plan language and all documents contained in your claim file, viewed as a whole."

Hartford then identified four specific pieces of information that it had considered: (1) "Medical records received from [an orthopedic surgeon,] Douglas Howard, M.D.[,] regarding your April 11, 2000 evaluation," (2) "Employability Analysis Report completed ... on March 22, 2001," (3) "Telephone conversation with you on November 28, 2000," and (4) "Telephone conversation with you on February 5, 2001."

Hartford explained:

The medical record completed by Dr. Howard on April 11, 2000 indicates that you are capable of working full time in an occupation that does not require repetitive use of your hands. Dr. Howard states that he does not find you totally disabled but only partially disabled. He indicates that you would be capable of performing a sedentary job on a full time basis that did not require repetitive use of your hands.

Hartford noted that although DiGregorio had indicated in the telephone conversations that she "would have [a different physician,] Dr. Jupiter[,] send medical information [to Hartford] concerning [her] condition[,][t]o date, this information has not been received. We do not have sufficient medical documentation to verify continued disability."

Finally, Hartford stated: "We have identified the following positions that you could perform based on your abilities as identified by Dr. Howard. These positions are both sedentary and do not require repetitive use of the hands." The positions were: "Customer-Complaint Clerk," "Insurance Clerk," "Information Clerk," and "Counter Clerk." Hartford determined that because DiGregorio could perform duties pertaining to these occupations, "for which [she was], or may be, qualified by education, training or expertise," she did not meet the Plan definition of Total Disability and was not entitled to LTD benefits.

Hartford then reiterated: "In reviewing your claim, [Hartford] considered your claim file as a whole for purposes of determining your eligibility [for] benefits under the Policy." Hartford concluded the denial letter by describing DiGregorio's rights "to appeal our decision and review pertinent documents in your claim file," as well as to submit

additional information not previously submitted which you believe will assist us in evaluating your claim for Long Term Disability benefits, .... [s]pecifically, medical documentation that you are unable to perform any occupation or work due to your abilities, training, education and experience, or documentation that you have a Disability which prevents you from performing other occupations.

C. DiGregorio's Requests for Her Entire Claim File

In a letter dated September 25, 2001, DiGregorio informed Hartford, through counsel, of her intent to appeal Hartford's decision to terminate her benefits and requested copies of "all documents upon which [Hartford] ha[d] relied ... in making [its] unfavorable determination," namely, her "entire claim file," including "[a]ny reports or other documents relating to or connected with a review of Ms. Di[G]regorio's medical records by a member of your medical department, or outside consultant."

That same day, September 25, 2001, Hartford provided copies of (1) an Employability Analysis Report prepared by a Hartford rehabilitation clinical case manager, dated March 22, 2001, which identified the four "Clerk" occupations Hartford alleged DiGregorio could perform, and (2) Dr. Howard's Follow-Up Orthopedic Evaluation based on his April 11, 2000 examination of DiGregorio, which documented her medical history and the results of his examination. According to the Evaluation, Dr. Howard made the following recommendation:

At this time I do not find [DiGregorio] totally disabled but only partially disabled. She should have no repetitive activities or repetitive use of the hands, but this would allow any type of sedentary occupation that was non-repetitive....

DiGregorio repeated her request for her entire claim file by letter from her counsel dated October 1, 2001. By letter of October 8, 2001, Hartford responded that "we cannot release any documents contained in Ms. Di[G]regorio's claim file that are not pertinent to the denial of her claim. The documents that accompanied our September 25, 2001 letter are those that were used in making our determination."

DiGregorio made a third request for her entire claim file through counsel by letter dated October 25, 2001, stating, "it is our position that you must have, and indeed should have, considered Ms. DiGregorio's entire claim file in making a decision to terminate benefits on this claim.... We believe Ms. DiGregorio is deprived [of] a full and fair review of her claim absent the provision of these materials." Hartford's reply by letter dated October 30, 2001 stated:

While Ms. DiGregorio's entire claim file has certainly been reviewed, the documents that pertain to the denial of her claim are . . . the Employability Analysis Report of 03/22/01 and the 04/11/01 evaluation by Dr. Douglas Howard. The most recent medical documentation we have on file indicates that Ms. DiGregorio is not Totally Disabled from any occupation, and, therefore, that is information used in making our determination to deny benefits.

D. DiGregorio's Appeal to Hartford

In her appeal letter to Hartford through counsel on November 8, 2001, DiGregorio presented her arguments in support of her claim to benefits, including her challenges to the accuracy and reliability of Dr. Howard's recommendation and the results of the Employability Analysis Report. DiGregorio also provided additional materials for Hartford's review, including: (1) a laboratory report from Massachusetts General Hospital showing the results of an Electromyography ("EMG") test conducted on DiGregorio on November 29, 2000, (2) a February 6, 2001 letter to DiGregorio from Dr. Jupiter, (3) a July 31, 2001 treatment note made by Dr. Jupiter, and (4) an October 12, 2001 letter to DiGregorio's attorney...