Rivera-Rivera et al v. Popular Inc. et al
Filing
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OPINION AND ORDER granting 46 Motion for Judgment; denying 47 . Signed by Judge Gustavo A. Gelpi on 2/22/2012. (JGF)
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IN THE UNITED STATES DISTRICT COURT
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FOR THE DISTRICT OF PUERTO RICO
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LUCY RIVERA-RIVERA,
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Plaintiff,
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v.
Civil Action No. 11-1245 (GAG)
HARTFORD LIFE & ACCIDENT
INSURANCE CO.,
Defendant.
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OPINION AND ORDER
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Plaintiff Lucy Rivera-Rivera (“Plaintiff”) brought this action against Hartford Life &
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Accident Insurance Co. (“Defendant”), seeking to recover benefits and damages under Sections 502
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(a)(1)(B) of the Employee Retirement Income Security Act (“ERISA”). Plaintiff commenced this
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action after the denial of her claim for long-term disability benefits under the Group Long Term
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Disability Plan (“Plan”) for employees of Popular, Inc. This matter is presently before the court on
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Plaintiff’s and Defendant’s cross-motions for judgment on the administrative record (Docket Nos.
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46 & 47). After reviewing the pertinent law, the court GRANTS Defendant’s motion for judgment
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on the administrative record at Docket No. 46 and DENIES Plaintiff’s motion at Docket No. 47.
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I.
Procedural and Factual History
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Plaintiff was employed by Popular Inc. for more than thirty years. (See Docket No. 1 ¶ 3.1.)
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Due to a purported illness, Plaintiff was unable to perform her duties, and requested long term
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disability (“LTD”) benefits under the Plan. (See id.) LTD benefits are included as part of the group
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insurance policy no. GLT675788 for employer Popular Inc. (See Docket No. 1 ¶ 1.1.)
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On March 11, 2010, Plaintiff filled out the original application for LTD insurance benefits
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(the “Application”). (See Docket 46-6 at 9.) On April 25, 2010, Defendant received Plaintiff’s
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Application in which Plaintiff claimed to have a disability of her nervous system, to be unable to sit
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and walk for long periods of time. Plaintiff further claimed that she was taking strong medication
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which affected her ability to work. (See Docket No. 46-4 at 46.) Plaintiff submitted she had this
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condition for the past fifteen years. (See Docket No. 46-4 at 45.) In the Application, Plaintiff
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identified Dr. Mary Miranda (“Dr. Miranda”), and Hospital Panamericano (“Hospital”) as the
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physician and hospital who treated her for her condition. (See Docket No. 46-4 at 46-47.) On April
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28, 2010, Defendant sent a letter to Plaintiff stating that her Application was incomplete and that she
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had twenty one days to produce the missing information. (See Docket No. 46-6 at 15.) Following
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receipt of the Application, Defendant sought to obtain Plaintiff’s medical records. On May 27, 2010,
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Defendant sent a letter to Dr. Miranda requesting Plaintiff’s records. (See Docket No. 46-5 at 58.)
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Having not received the information, on June 24, 2010, Defendant again requested that Dr. Miranda
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provide Plaintiff’s medical records. (See Docket No. 46-5 at 59.) On that same date, Defendant
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informed Plaintiff that Dr. Miranda had not responded to its request and urged Plaintiff to contact
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Dr. Miranda to assist in this effort. (See Docket No. 46-6 at 18.) On July 7, 2010, Defendant once
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more asked Plaintiff to contact Dr. Miranda and request that her records be provided to Defendant.
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(See Docket No. 46-6 at 21.) On July 14, 2010, Defendant received Plaintiff’s medical records from
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Dr. Miranda. (See Docket No. 46-6 at 23 -26.) On August 10, 2010, Defendant denied Plaintiff’s
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Application for LTD benefits. (See Docket No. 46-6 at 30.) On August 23, 2010, Plaintiff appealed
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Defendant’s denial of LTD benefits. (See Docket No. 46-6 at 35.) On October 22, 2010, Defendant
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denied the appeal. (See Docket No. 46-6 at 45.)
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II.
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Standard of Review
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Under ERISA’s civil enforcement provision, Section 502 (a)(1)(B), judicial review of a
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benefit entitlement decision may be the subject of two separate standards. Eusebio Cotto Villegas
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v. Fed. Express Corp., 468 F. Supp. 2d, 306 (D.P.R. 2006) (stating the two possible standards of
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review are arbitrary and capricious or de novo). The arbitrary and capricious standard applies if a
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reading of the plan in question indicates a clear grant of discretionary authority to the administrator
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in determining the eligibility for benefits of a participant or beneficiary. See Terry v. Bayer Corp.,
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145 F.3d 28, 37 (1st Cir. 1998). If the plan “gives the administrator or fiduciary discretionary
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authority to determine eligibility for benefits or to construe the terms of the plan,” then the court
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must apply the deferential “arbitrary and capricious” standard of review. Firestone Tire and Rubber
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Co. v. Bruch, 489 U.S. 101; Leahy, 315 F.3d at 15. “This standard means that the administrator’s
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decision will be upheld if it is reasoned and supported by substantial evidence in the record.” Doyle
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v. Paul Revere Life Ins. Co., 144 F.3d 181, 184 (1st Cir. 1998) (quoting Assoc. Fisheries of Maine,
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Inc. v. Daley, 127 F.3d 104, 109 (1st Cir. 1997)); see Vlass v. Raytheon Emp. Disability Trust, 244
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F.3d 27, 30 (1st Cir. 2001). “Evidence is ‘substantial’ if it is reasonably sufficient to support a
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conclusion.” Vlass, 244 F.3d at 30 (citations omitted). “Moreover, the existence of contradictory
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evidence does not, in itself, make the administrator’s decision arbitrary.” Id. (citations omitted).
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In defining this standard, the Supreme Court has directed reviewing courts to “ consider
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whether the [agency] decision was based on a consideration of the relevant factors and whether there
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has been a clear error of judgment. ” Bowman Transp., Inc. v. Arkansas-Best Freight Syst., Inc., 419
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U.S. 281, 285, (1974); see also Citizens To Preserve Overton Park, Inc. v. Volpe, 401 U.S. 402,
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415-17(1971). This standard of review is a “narrow” one, requiring that a court not “substitute its
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judgment for that of the [administrator] . . . .” Motor Vehicle Mfrs. Ass’n of U.S., Inc. v. State Farm
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Mut. Auto. Ins. Co., 463 U.S. 29. Where such a clear grant of discretionary authority is not apparent,
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the standard of review is de novo. Firestone, 489 U.S. at 115; see also Rodriguez-Abreu v. Chase
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Manhattan Bank, N.A., 986 F.2d 580, 583 (1st Cir. 1993).
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Furthermore, the First Circuit has held “that a conflict of interest does not change the
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standard or review from deferential to de novo.” Diaz v. Metro. Life Ins. Co., 688 F. Supp. 2d 49,
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60 (D.P.R. 2010) (citing Cusson v. Liberty Life Assur. Co. of Boston, 592 F.3d 215, 224 (1st Cir.
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2010)). The fact that an administrator both determines entitlement benefits and pays the benefits
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does not present such a serious conflict of interest. Sanchez-Figueroa v. Seguros de Vida Triple S,
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Inc., 2006 WL 2847385 at *11 (D.P.R. Sep. 29, 2006) (citing Doyle, 144 F.3d at 184). In situations
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where the conflict of interest is purely structural –i.e., when the insurer of an ERISA plan also serves
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as plan administrator– courts “must apply arbitrary and capricious review.” Denmark v. Liberty Life
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Assur. Co. of Boston, 481 F.3d 16. “[S]pecial emphasis should be paid on reasonableness . . . with
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the burden on the claimant to show that the decision was improperly motivated.” Sanchez-Figueroa,
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2006 WL 2847385 at *11 (quoting Doyle, 144 F.3d at 184) (internal quotation marks omitted).
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III.
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Discussion
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In the case at bar, the ERISA information section of the LTD policy contains a provision
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entitled “Claims Procedures.” (See Docket No. 46-4 at 39.) The Claims Procedures provides that
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“the Plan has designated and named the Insurance Company full discretion and authority to
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determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.”
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(See Docket No. 46-4 at 39 ¶ 8.) In addition, the two provisions in the ERISA information section
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concerning Defendant’s discretion, provide that: “We have full discretion and authority to determine
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eligibility for benefits and to construe and interpret all terms and provisions of the Policy.” (See
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Docket No. 46-4 at 27.) Based upon First Circuit precedent, the court finds that this language is
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more than sufficient to grant discretionary authority to Defendant, and thus, the matter before the
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court will be analyzed under the “arbitrary and capricious” standard of review. See Wright v. R.R.
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Donelley & Sons Co., (1st Cir. 2005).
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Plaintiff claimed November 30, 2009 was the first day she was unable to work due to an
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alleged disabling condition. (See Docket No. 46-4 at 46.) As part of the Application, Plaintiff
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submitted Dr. Miranda’s statement of disability. (See Docket No. 46-5 at 2 - 3.) Dr. Miranda stated
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that Plaintiff’s primary diagnosis was Diabetes Mellitus II and her secondary diagnosis was
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neuropathy, anxiety disorder and morbid obesity. (See Docket No. 46-5 at 2.) Dr. Miranda further
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informed that Plaintiff’s symptoms were anxiety and depression. (See Docket No. 46-5 at 2.)
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Dr. Miranda’s notes contain an entry dated November 12, 2009, less than three weeks prior
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to the date on which Plaintiff claims she became disabled, which reflect that Plaintiff had been
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hospitalized due to depression. (See Docket No. 46-5 at 53.) Dr. Miranda’s notes reflect that her
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plan was to restart medical treatment because patient “was unable to work at this moment .” (See
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Docket No. 46-5 at 53.)
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Plaintiff’s next appointment was on December 1, 2009, the day after Plaintiff claims she
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became disabled. (See Docket No. 46-5 at 53.) Plaintiff had another appointment on March 11,
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2010 and her final appointment was on June 10, 2010, at which time, Dr. Miranda noted Plaintiff’s
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lab results and made adjustments to her diabetes medication. (See Docket No. 46-5 at 54 - 55.)
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Defendant informed Plaintiff that Dr. Miranda’s opinion was that Plaintiff could stand for
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one hour periods of time, walk for half to one hour periods of time, sit for two hour periods of time,
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and perform repetitive keyboard use for half hour periods of time. (See 46-6 at 31.) Defendant
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further informed Plaintiff that her medical records did not indicate a disability which prevented her
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from being able to perform the duties of a customer service representative at any time beyond
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November 30, 2009. (See Docket No. 46-6 at 31-32.) Because the medical records and the
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information provided by Dr. Miranda did not substantiate any medical conditions that prohibited
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Plaintiff from being able to perform her job duties, Defendant denied Plaintiff’s claim and notified
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her of the opportunity to file an appeal. (See Docket No. 46-6 at 30-33.)
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Plaintiff filed her appeal on August 17, 2010. (See Docket No. 46-6 at 35-36.) Defendant
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recieved Plaintiff’s appeal on August 29, 2010. (See id.) In her appeal, Plaintiff did not provide any
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medical information to support her claim, rather she claimed that she had worked for the past 5 years
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as severely handicapped and her social security disability claim had been approved. On September
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28, 2010, Defendant requested that Plaintiff provide Defendant with all of her medical records from
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November 2009 to the present, along with any medical information provided to the Social Security
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Administration (“SSA”) or that it obtained in connection with her SSA application. (See Docket No.
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46-6 at 40.) Plaintiff claimed she did not have any information from the SSA and that she had
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already provided Dr. Miranda’s records. (See Docket No. 46-6 at 42-43.) Plaintiff did provide
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Defendant with records of her hospitalization records in October 2009. (See Docket No. 46-6 at 46
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¶ 2.) The hospital records reflect that Plaintiff was admitted for treatment due to symptoms of
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depression on October 5, 2009. (See Docket No. 46-5 at 85.) While hospitalized, Plaintiff’s mood
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gradually improved and she requested a reduction in medication, which she had tolerated well. (See
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Docket No. 46-5 at 85.) On October 16, 2009, Plaintiff was discharged, at which time she was
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“observed as alert, coherent and logical, oriented in three spheres.” (See Docket No. 46-5 at 85.)
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As part of her treatment while hospitalized, Plaintiff received occupational therapy in which she
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received the maximum grades on all items as to which she was graded. (See Docket No. 46-5 at 87.)
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Through an October 22, 2010 letter from Defendant’s Appeals Specialist Deanie Wallis
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(“Wallis”) to Plaintiff, Defendant upheld its denial of Plaintiff’s benefit claim. (See Docket No. 46-6
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at 45-46.) Wallis explained that none of Dr. Miranda’s medical records contained any records of
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physical examinations or discussions of Plaintiff’s functionality, which substantiated Plaintiff’s
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inability to perform her occupational duties. (See id.)
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In addition to explaining that Dr. Miranda’s records did not evidence any functional
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limitations substantiating disability, Ms. Wallis explained that the hospital records Plaintiff provided
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evidenced that she was hospitalized more than forty five days prior to her last day of work for
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depression, and that upon discharge, Plaintiff was stable, alert, coherent and logical. (See Docket
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No. 46-6 at 46.) Wallis explained that this information did not establish that Plaintiff was precluded
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by disability from performing the duties of her profession. (See id.)
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Upon review of the administrative record, the court finds that the administrator’s decision
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was impartial, not influenced by documents or other evidence not found in the record. The
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Administrator stated she relied upon medical and hospital records in order to reach the conclusion
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that Plaintiff did not meet the standards for LTD benefits. (See Docket No. 46-6 at 45-46.) The court
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finds that it is reasonable for the Administrator to use these documents in order to reach a decision
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as to Plaintiff’s LTD benefits. The court finds this decision was made in a reasonable manner,
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therefore it was not made arbitrarily or capriciously. The decision was based on the documents
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submitted by Plaintiff as well as medical and hospital records. (See id.)
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IV.
Conclusion
For the foregoing reasons, the court GRANTS Defendant’s motion for judgment on the
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administrative record (Docket No. 46) and DENIES Plaintiff’s Motion (Docket No. 47).
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the court’s ruling in this matter, it becomes unnecessary for the court to address plaintiff’s other
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claims.
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Given
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SO ORDERED
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In San Juan, Puerto Rico this 22nd day of February, 2012.
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S/Gustavo A. Gelpí
GUSTAVO A. GELPÍ
United States District Judge
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