Lopes v. Metropolitan Life Ins. Co.

• Decision Date: 09 June 2003
• Docket Number: No. 02-2273.,02-2273.
• Parties: George LOPES, Plaintiff, Appellant, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant, Appellee.
• Court: U.S. Court of Appeals — First Circuit

Page 1

332 F.3d 1

George LOPES, Plaintiff, Appellant, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant, Appellee.

No. 02-2273.

United States Court of Appeals, First Circuit.

Heard March 3, 2003.

Decided June 9, 2003.

Howard I. Rosen, with whom Newman & Newman, P.C. were on brief, for Appellant.

Stephen S. Churchill, with whom James F. Kavanaugh, Jr. and Conn, Kavanaugh, Rosenthal, Peisch & Ford, LLP were on brief, for Appellee.

Before LYNCH, Circuit Judge, BOWNES, Senior Circuit Judge, and HOWARD, Circuit Judge.

HOWARD, Circuit Judge.

Plaintiff-appellant George Lopes appeals from an adverse summary judgment ruling holding that defendant-appellee Metropolitan Life Insurance Company ("MetLife") did not violate the Employment Retirement Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461, in terminating his long-term disability benefits. We affirm.

I.

Lopes began working at Fischbach Corporation in 1969. He eventually became a Signal Project engineer, supervising the installation of signal and electrical equipment. While employed at Fischbach, Lopes was enrolled as a participant in the MetLife-sponsored Fischbach Group Insurance Plan ("the Plan"). The Plan provides for long-term disability benefits for the first twenty-four months of disability if a physical impairment prevents the employee from working in his regular occupation. To qualify for benefits after that period, the plan participant must either be "completely and continuously unable to perform the duties of any gainful work or service for which [he is] reasonably qualified taking into consideration [his] training, education, and experience and past earnings," or have suffered a 50% (or more) loss of earnings capacity.

In early 1996, Lopes was diagnosed with stage IV pulmonary sarcoidosis, a chronic inflammation of the lungs. Lopes stopped working at Fischbach on February 20, 1996, and shortly thereafter filed for long-term disability benefits under the Plan. On May 28, 1996, Lopes underwent a right lung transplant. Subsequently, Lopes' attending physician, Dr. Lynda Cristiano, filed a statement with MetLife characterizing Lopes' impairment as "Class 5" (on a scale from 1 to 5) and totally disabling.¹ Nonetheless, Dr. Cristiano also opined that Lopes was a "suitable candidate for future rehabilitation." MetLife began paying Lopes benefits on August 18, 1996.

During the next two years, Lopes received disability payments from the Plan and followed a rehabilitation program. But Lopes' health was precarious: he underwent several bronchoscopies, lung tissue biopsies, and was twice hospitalized for possible pneumonia or infection. Lopes also suffered from "post right lung transplant," sarcoidosis, hypertension, hypercholesterol, diabetes mellitus, right bronchial stenosis, and renal failure. Consequently, he required ongoing medical supervision and several medications.

Between 1997 and 1999, Drs. Edward P. Ingenito and Aaron Deykin (who were then treating Lopes) submitted to MetLife two physician's statements in which they characterized Lopes' impairment as "Class 5" and totally disabling. During this same period, they also completed several physical capacities evaluations in which they indicated that Lopes' physical abilities were limited. Over time, however, these evaluations did note improvement in his ability to lift and carry objects and to perform other everyday physical activities such as grasping, bending, and reaching above shoulder level.

Under the Plan, MetLife reevaluated Lopes' eligibility for continued benefits after twenty-four months. At that point, MetLife's definition of disability became more spartan:

However, after the first 24 months of benefit payments, you must also be completely and continuously unable to perform the duties of any gainful work or service for which you are reasonably qualified taking into consideration your training, education, and experience and past earnings.

In short, Lopes would only continue receiving benefits if his illness prevented him from performing any job that matched his skill set.

On October 3, 2000, Dr. Ingenito submitted the final physician's statement MetLife received before terminating Lopes' benefits. For the first time, Dr. Ingenito characterized his physical impairment as "Class 4," which signifies a "moderate limitation of functional capacity," and implies a capability to engage in "clerical/administrative ([]sedentary) activity."² Nevertheless, despite describing the impairment as "Class 4," Dr. Ingenito opined that Lopes remained "totally disabled" from performing his former occupation and any other work, and that he lacked prospects for significant improvement.

On February 7, 2001, MetLife wrote Lopes and advised him that it had terminated his disability benefits on January 31, 2001. The letter explained that Lopes was no longer totally disabled under the Plan based on Lopes' most recent medical information, a vocational assessment, and all of the medical evidence contained in Lopes' file. MetLife relied heavily on Dr. Ingenito's report in explaining its decision:

You can lift and carry up to twenty pounds frequently, you can bend and reach above shoulder level frequently, you can squat, crawl, climb, occasionally, operate a motor vehicle, and use both your hands to perform repetitive fine finger movements, eye/hand movements and pushing and pulling. [Dr. Ingenito] states that in regards to physical impairment you have moderate limitation of functional capacity, you are capable of clerical/administrative work, sedentary activity.

Citing a "transferable skills analysis" completed by a vocational skills consultant, the letter identified several occupations for which Lopes qualified.³

Although not mentioned in the letter, MetLife also considered an analysis of Lopes' vocational prospects conducted by Dr. R. Kevin Smith, a board-certified Doctor of Osteopathy in Preventative and Occupational Medicine. Dr. Smith did not personally examine Lopes, but rather based his evaluation on the information in MetLife's file, including the physicians' reports and the vocational assessment. Smith concluded that Lopes' physical condition had stabilized and that Lopes was capable of performing a full-time sedentary job.

Lopes appealed MetLife's decision to terminate his benefits by letter dated August 10, 2001. Lopes attached to his letter a list of eleven medications and supplements that he was taking regularly, and promised to submit additional medical information. On October 3, 2001, MetLife denied Lopes' appeal. In its denial, MetLife reiterated its rationale for terminating Lopes' benefits, placing particular emphasis on Lopes' apparent ability to engage in sedentary activity. MetLife also noted that, notwithstanding Lopes' promise to submit additional materials, "there were no current medical records in file."

Subsequently, Lopes sued MetLife in Massachusetts superior court, claiming that MetLife's decision to terminate his benefits violated state statutory and common law. On February 22, 2000, MetLife removed this matter to the United States District Court for the District of Massachusetts on the basis of ERISA preemption. See Metropolitan Life Ins. Co. v. Taylor, 481 U.S. 58, 66-67, 107 S.Ct. 1542, 95 L.Ed.2d 55(1987). Lopes then amended his complaint to allege a violation of ERISA § 1132(a)(1)(b).⁴ In due course, the parties cross-moved for summary judgment.

Because the Plan vests discretionary authority in MetLife to determine eligibility for benefits or to construe its terms,⁵ the district court first determined that it would not upset MetLife's termination of Lopes' benefits unless it found the termination to be arbitrary and capricious. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 111, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)(directing courts to accord deference to benefit determinations made under plans that vest discretionary decision-making authority in their administrators). In so ruling, the court rejected Lopes' arguments in favor of de novo review, that MetLife (1) acted under a conflict of interest as both the insurer and plan administrator, and (2) acted with improper motivation in terminating his benefits. See Pari-Fasano v. ITT Hartford Life & Accident Ins. Co., 230 F.3d 415, 419-20 (1st Cir.2000)(rejecting an argument in favor of a less deferential standard of review in similar circumstances, but emphasizing that dual role evidence or evidence of improper motivation would factor into the functionally equivalent inquiries into whether the administrator's decision was "arbitrary and capricious," an "abuse of discretion," or "unreasonable"). The court then determined that, based on the evidence that was before it, MetLife acted reasonably in terminating Lopes' benefits. Accordingly, the court granted MetLife's cross-motion for summary judgment and denied Lopes' cross-motion. This appeal followed.

II.

On appeal, Lopes renews his arguments in favor of de novo review and urges us to consider evidence outside the administrative record. Alternatively, Lopes contends that MetLife's decision was erroneous even under a more deferential standard of review. We reject Lopes' arguments for de novo review without further elaboration because they are precluded by settled circuit precedent. See Pari-Fasano, 230 F.3d at 419-20; see also supra at 4 (summarizing Pari-Fasano's explanation how benefits determinations are to be reviewed in circumstances such as this).⁶ We also reject Lopes' argument in favor of supplementing the administrative record with additional medical evidence. Finally, we reject Lopes' attack on the merits of MetLife's decision. While the evidence before MetLife did not compel a conclusion that Lopes could return to work, it was of such a nature as to render the conclusion a permissible exercise of MetLife's discretion.

Before addressing the merits of MetLife's decision, we first address Lopes' argument that, given MetLife's potential bias, we should...