Carrucini v. Triple-S Vida, Inc.
Filing
40
OPINION AND ORDER denying 19 Motion for Summary Judgment; granting 28 Amended Motion for Summary Judgment. Signed by US Magistrate Judge Silvia Carreno-Coll on 3/25/2015.(NBB)
IN THE UNITED STATES COURT
FOR THE DISTRICT OF PUERTO RICO
ZORAIDA CARRUCINI,
Plaintiff,
v.
CIV. NO.: 14-1168(SCC)
TRIPLE-S VIDA, INC.,
Defendant.
OPINION AND ORDER
Plaintiff Zoraida Carrucini, a former employee of Cutler
Hammer Electrical Company, filed a complaint in the Court of
First Instance in Bayamón against Defendant Triple-S Vida,
Inc., “the administrator and insurer of” Cutler Hammer’s
disability insurance program. Docket No. 1-2, at 2. According
to the complaint, Triple-S wrongly denied Carrucini long-term
disability benefits. See id. at 2–5. Though the complaint did not
mention the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. §§ 1001–1461, Triple-S removed the case
CARRUCINI v. TRIPLE-S
Page 2
to federal court on the grounds that her state-law cause of
action was preempted by ERISA, which provides the only
permissible means for her to challenge her denial of benefits.
Docket No. 1, at 2–3. Carrucini sought remand, arguing that
federal jurisdiction had not been established1 and that Triple-S
had missed the deadline to seek removal. Docket No. 6, at 1–2.
The Court denied Carrucini’s remand motion, Docket No. 7,
and after discovery the parties filed cross-motions for summary judgment, Docket Nos. 19, 28, which are now before me.2
For the reasons I explain below, I grant Carrucini’s motion and
deny Triple-S’s.
I. Factual Background
Plaintiff Zoraida Carrucini was an employee of Cutler
Hammer Electrical Company, where she worked as a senior
human resources representative. Her position was classified as
a sedentary position, requiring continuous sitting and no other
1.
The argument that jurisdiction had not been established was
conclusory, but Carrucini also requested “discovery for the purpose of
determining whether the insurance contract is an ERISA plan.” Docket
No. 6, at 2. The Court agreed that discovery might be necessary to
determine whether ERISA preemption in fact applied. Docket No. 7.
2.
Notably, Carrucini, in her motion for summary judgment, does not
dispute that ERISA controls this case.
CARRUCINI v. TRIPLE-S
Page 3
exertional requirements apart from the occasional climbing of
stairs. Docket No. 27-2, at 45, 47. The position also required
“constant” computer use. Id. at 47. Among the essential
functions of Carrucini’s position was liaising between the
community and the company. Docket No. 27-2, at 49. Her
position also included external contacts such as recruiting and
participating in community programs. Docket No. 27-3, at 1.
On account of a number of medical conditions,3 Carrucini
applied for disability insurance pursuant to her employer’
group plan. She quit working on April 10, 2012, and never
returned.
As an employee of Cutler Hammer, Carrucini was a
beneficiary of the Group Long Term Disability Insurance Plan
(“the Plan”). See Docket No. 27-1, at 1. This policy was issued
by Defendant Triple-S Vida, Inc., which reserved to itself “the
discretionary authority to determine [beneficiaries’] eligibility
for benefits and to construe the terms of the policy to make a
benefits determination.” Id. at 47. To receive benefits under the
3.
According to Carrucini, these include fibromyalgia; carpal tunnel
syndrome; degenerative disc disease; severe chronic lumbar, sacral, and
cervical pain; cervical radiculopathy; lumbar and cervical spondylosis;
apnea; and major depressive disorder.
CARRUCINI v. TRIPLE-S
Page 4
Plan, a person is required to complete a claim form. Either the
employer or the person’s treating physician must also complete
certain parts of the form. After the form is filled out, it must be
sent to Triple-S. Eligibility for benefits is determined pursuant
to the Plan’s definition of disability. In relevant part, this
definition requires that Triple-S find that “during the elimination period,” the person was
prevent[ed] from performing with reasonable continuity the material and substantial duties of [her] regular
occupation and a reasonable employment option
offered to [her] by the employer and, as a result, [she] is
not working at all, or [she] is working and the income
[she] is able to earn is less than or equal to 20% of [her]
pre-disability earnings.
Id. at 26. The phrase “elimination period” refers to a “period of
continuous days of total disability,” which “begins on the first
day of” a person’s disability and continues for 180 days. Id. at
11, 28.4
4.
In her motion for summary judgment, Carrucini argues that the
elimination period need not elapse consecutively in every case, because
“one may return to work and not be required to begin a new
elimination period.” Docket No. 28, at 20. Triple-S acknowledges the
truth of this statement, but correctly notes that it is irrelevant given that
Carrucini never returned to work. Docket No. 32, at 16.
CARRUCINI v. TRIPLE-S
Page 5
As Carrucini quit working on April 10, 2012, her elimination period began the next day, on April 11, 2012. Triple-S
received Carrucini’s long-term disability application on
October 24, 2012, and it subsequently sent a letter to Cutler
Hammer requesting certain pertinent information. During a
November 20, 2012, phone call, Carrucini provided Triple-S
with various information regarding her personal, health, and
work histories. Yet more information was requested from
Carrucini on November 27 and December 26, 2012, and after
Cutler Hammer apparently didn’t respond to a first request,
Triple-S again asked it to provide information regarding
Carrucini.
As part of Triple-S’s review of Carrucini’s claim, it had a
clinical review prepared by Darcy Newton, a registered nurse.
See Docket No. 27-14, at 11–16. Newton summarized
Carrucini’s medical records and concluded that her diagnoses
were “not causing a complete loss of functional capacity.” Id.
at 16. Newton wrote that Carrucini could “sit, stand, walk and
alternate continuously for 1 hour each with periods of rest.” Id.
Newton noted that Carrucini’s doctors recommended that
repetitive tasks be avoided. Furthermore, several of Carrucini’s
treating physicians determined that Carrucini could not travel
CARRUCINI v. TRIPLE-S
Page 6
unless it was absolutely necessary.
On January 23, 2013, Triple-S sent Carrucini a letter
informing her of the denial of her disability request. According
to that letter, Triple-S determined that Carrucini did not
experience limitations preventing her from performing her job
during the elimination period. Carrucini appealed Triple-S’s
decision on April 24, 2013. With her appeal, Carrucini provided
additional medical evidence. Triple-S had Carrucini’s appeal
file reviewed by two independent, non-examining medical
professionals, Dr. Jaime Foland, a physician, and Dr. Marla
Rodríguez, a psychologist.5
As part of his review, Dr. Foland spoke twice with
Carrucini’s rheumatologist, Dr. Miguel Ramírez-Soto. In a
letter to Dr. Ramírez-Soto, Dr. Foland summarized Dr.
Ramírez-Soto’s diagnosis as one of fibromyalgia, chronic pain,
5.
Carrucini suggests that the independent physicians, and especially Dr.
Rodríguez, were biased. See, e.g., Docket No. 20, at 19 (“Dra. Rodriguez
in her zeal to accommodate her review to her employer’s position . . .
and to its lucrative practice was blinded to the obvious.”). I note,
however, that without actual evidence of bias, there is nothing
inherently inappropriate about a plan administrator’s use of outside
experts. See, e.g., Leahy v. Raytheon Co., 315 F.3d 11, 16 (1st Cir. 2002)
(“We are aware of no case holding that a plan administrator operates
under a conflict of interest simply by securing independent medical
advice to aid in the evaluation process.”).
CARRUCINI v. TRIPLE-S
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neck pain, lower back pain, carpal tunnel syndrome, and
osteopenia. According to the letter, Dr. Ramírez-Soto also
believed that Carrucini’s fibromyalgia was aggravating her
depression, for which she had been prescribed lithium by a
psychiatrist. Finally, the letter indicated that Dr. Ramírez-Soto
had advised Carrucini not to return to work. Dr. Foland sent
a copy of his letter to Dr. Ramírez-Soto asking that it be signed
and returned with any additional comments; Dr. Ramírez-Soto
signed and returned the letter without comments.
Dr. Foland spoke with Carrucini’s neurologist, Dr. Luis
Forastieri-Maldonado, following a similar procedure.6 Dr.
Forastieri had also diagnosed fibromyalgia, along with
probable carpal tunnel syndrome and cervical radiculopathy.
Carrucini’s internist, Dr. Miguel Rodríguez-Soberal, told Dr.
Foland that he, too, had diagnosed Carrucini with
fibromyalgia, which he believed to be a symptom of
Carrucini’s depression.7 Finally, Dr. Foland spoke with
Carrucini’s physiatrist, Dr. Beatriz Bartolomei-Aguilera. Dr.
6.
However, Dr. Forastieri did not return the letter from Dr. Foland.
7.
Like Dr. Forastieri, Dr. Rodríguez did not return the letter from Dr.
Foland.
CARRUCINI v. TRIPLE-S
Page 8
Bartolomei, who told Dr. Foland that Carrucini did not have
structural problems, but instead had nerve pain; Carrucini also
had a positive straight leg raise, but negative Lasegue’s and no
muscle atrophy. Dr. Bartolomei also found that Carrucini had
frequent muscle spasms and nerve root lesions on her back. Dr.
Bartolomei told Dr. Foland that she did not think that Carrucini could return to work. In addition to lithium, the doctors
consulted by Dr. Foland reported that Carrucini took Cymbalta
for her nerve pain and Lyrica for her fibromyalgia.
Based on his conversations with Carrucini’s treating
physicians, as well as his review of the other medical evidence
in the record, Dr. Foland concluded that Carrucini had
“spondylosis as would be expected in someone [her] age.”
However, Dr. Foland found no diagnostic evidence of “central
or lateral stenosis which would be compromising either the
nerve roots or the spinal cord.” Thus, he found that there were
“no physical conditions supported by the clinical evidence that
are functionally impairing.” Though he noted that the records
revealed fibromyalgia and spondylosis, he found that they
were “not functionally impairing.” This was because “[f]ibromyalgia is a treatable condition.” Dr. Foland concluded that
there was no evidence of a physical condition disabling
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Page 9
Carrucini.
Dr. Marla Rodríguez reviewed Carrucini’s health from a
mental health perspective. Following the same procedure as
did Dr. Foland, Carrucini’s psychiatrist, Dr. Flores Santa, told
Dr. Rodríguez that she saw Carrucini monthly, but that in the
past Carrucini had not attended treatment regularly. Dr. Santa
said that in her last visit, Carrucini was “alert, fully oriented
and cooperative,” and that her thoughts “were coherent,
logical, and relevant.” Dr. Santa said that Carrucini reported
problems with concentration and, occasionally, understanding
instructions; in response to Dr. Rodríguez’s questions, however, Dr. Santa said that in her last visit, Carrucini had been
able to understand Dr. Santa. Dr. Santa said that Carrucini took
lithium, Cymbalta, and Klonopin. She furthermore reported
that Carrucini had initially responded positively to treatment
but underwent psychiatric hospitalization in 2010 and 2013.
Dr. Rodríguez also reviewed Carrucini’s psychiatric
treatment notes. Reviewing the notes from Psychotherapeutic
Health Systems, Dr. Rodríguez noted that Carrucini had
logical, relevant, and coherent thoughts, and that her condition
seemed stable from 2011 to 2013. Dr. Rodríguez further noted
that treatment notes from Dr. Luis Pio Sánchez-Caso and the
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Instituto para el Manejo del Dolor de Puerto Rico y el Caribe
did not contain any psychological diagnoses or symptoms.
However, progress notes from Carde Gómez, dated September
4, 2012, showed a diagnosis of bipolar II, depression, and major
depression. Carrucini’s GAF was set by Gómez at 65.8
Dr. Rodríguez noted that Carrucini had admitted herself to
a hospital for psychiatric care on October 14, 2012, reporting
suicidal ideation. Carrucini was released on October 22, 2012,
with a diagnosis of bipolar disorder, with a GAF of 50. With
regard to daily life activities, Dr. Rodríguez stated that Carrucini reported being able to cook, clean, and wash clothes.
Carrucini reported driving, as well as attending church,
receiving visitors, watching television and reading for recreation.
Dr. Rodríguez concluded that Carrucini’s symptoms were
not consistent with a severe psychological condition during the
8.
GAF refers to the Global Assessment of Functioning, which measures,
on a 1–100 scale, a person’s ability to function. 2 Dan J. Tennenhouse,
Attorney’s Medical Deskbook § 18:10 (4th ed.). During one
hospitilization, Carrucini’s GAF was 50. Scores of 40 and below
indicate severe dysfunction, while scores of 80 or better “signify
excellent functioning.” Id. Carrucini’s scores thus reflect diminished,
but not necessarily severely diminished, functioning.
CARRUCINI v. TRIPLE-S
Page 11
elimination period. Dr. Rodríguez found a conflict in
Carrucini’s self-reported symptoms.9 Given that Carrucini
reported performing various activities of daily life, as well as
being a caretaker for her adult son, who suffers from a mental
disability, Dr. Rodríguez concluded that Carrucini’s level of
activity was inconsistent with an impairment of cognitive
function.
On the basis of these reports, Triple-S concluded that there
was insufficient evidence to support Carrucini’s claims of a
disability that prevented her from performing her job’s
essential duties.10 Triple-S made this finding despite the Social
Security Administration determining that Carrucini was
disabled.
9.
The primary inconsistency noted by Dr. Rodríguez, according to TripleS’s statement of uncontested facts, regards the origin or Carrucini’s
son’s disability. Further, Dr. Rodríguez noted that Carrucini’s reports
of daily functions do not mention living with or caring for an adult son.
10. To be clear, the letter by which Triple-S informed Carrucini of its denial
of her claim relies entirely on the analyses of Dr. Foland and Dr.
Rodríguez. See Docket No. 27-48, at 16–28. In fact, their employer,
Custom Disability Solutions, wrote a draft denial letter that is
substantially identical to the letter actually sent to Carrucini. See id. at
30–36.
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II. Analysis
Though a motion for summary judgment is before me, the
standard of review to be applied differs somewhat from the
typical case. A court reviewing a denial of benefits under
ERISA applies different standards of review based “upon
whether ‘the benefits plan gives the administrator or fiduciary
discretionary authority to determine eligibility for benefits or
to construe the terms of the plan.’” Leahy v. Raytheon Co., 315
F.3d 11, 15 (1st Cir. 2002) (quoting Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 115 (1989)). Where such discretion exists,
courts apply “a deferential ‘arbitrary and capricious’ standard
of review” to the denial of benefits. Recupero v. New Engl. Tel.
& Tel. Co., 118 F.3d 820, 827 (1st Cir. 1997) (quoting Firestone,
489 U.S. at 115). Otherwise, a de novo standard obtains.
Firestone, 489 U.S. at 115.
Here, Triple-S contends that the arbitrary and capricious
standard applies, while Carrucini contends that the a more
searching review is appropriate. The policy covering Carrucini
states that Triple-S is the insurer. Docket No. 27-1, at 1. In
language echoing Firestone, the policy reserves to Triple-S “the
discretionary authority to determine [the beneficiary’s]
eligibility for benefits and to construe the terms of the policy to
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Page 13
make a benefits determination.” Id. at 47. The First Circuit has
found similar language sufficient to require the use of the
arbitrary and capricious standard. See, e.g., Leahy, 315 F.3d at 15
(giving the administrator “the exclusive right, in [its] sole
discretion, to interpret the Plan and decide all matters arising
thereunder”); see also Matias-Correa v. Pfizer, Inc., 345 F.3d 7, 11
(1st Cir. 2003) (similar). Carrucini objects to this reasoning
because the record contains no language explicitly naming
Triple-S as plan administrator.
In the First Circuit, “a party may be treated as a plan
administrator where it is shown to control the administration
of the plan.” Law v. Ernst & Young, 956 F.2d 364, 372 (1st Cir.
1992);11 see also Hamilton v. Allen-Bradley Co., 244 F.3d 819, 824
(“Proof of who is the plan administrator may come from the
plan document, but can also come from the factual circumstances surrounding the administration of the plan . . . .”).
Here, as noted above, the record—indeed, the plan itself—makes plain that Triple-S carries out the plan’s administration, despite not being specifically designated as the
11. I note that some courts have rejected this rule. See, e.g., Warren Pearl
Constr. Corp. v. Guardian Life Ins. Co. of Am., 639 F. Supp. 2d 371, 380
(S.D.N.Y. 2009) (explaining that the Second Circuit has rejected Law).
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administrator. See Hamilton, 244 F.3d at 824 (looking at whether
plan gave putative administrator authority to administer the
plan); see also Byrd v. Canadian Imperial Bank of Commerce, 354 F.
Supp. 2d 597, 607 (D.S.C. 2005) (following Hamilton), aff’d, 157
F. App’x 643 (4th Cir. 2005). I accordingly find that Triple-S is
a plan administrator to which discretionary authority has been
reserved. Arbitrary and capricious review therefore applies.12
With the matter of standards of review out of the way, I
proceed to the question of whether substantial evidence
supported Triple-S’s denial of benefits. This is a “deferential
standard of review,” Ortega-Candelaria v. Johnson & Johnson, 755
F.3d 13, 20 (1st Cir. 2014), that is concerned with whether the
12. In the alternative, I would find that Triple-S was a plan fiduciary,
which would also require the application of arbitrary and capricious
review. Under ERISA, a person is “a fiduciary with respect to a plan to
the extent that . . . he has any discretionary authority or discretionary
responsibility in the administration of such plan.” 29 U.S.C.
§ 1002(21)(A). The Plan in this case gives Triple-S such discretionary
authority, making Triple-S a fiduciary with respect to the Plan. Cf. Byrd
v. Canadian Imperial Bank of Commerce, 354 F. Supp. 2d 597, 607 n.15
(D.S.C. 2005) (finding the insurer to be a plan fiduciary under similar
circumstances). And Leahy requires that where a benefits decision was
made by a fiduciary with discretionary authority, arbitrary and
capricious review be applied. 315 F.3d at 15. Thus, regardless of
whether Triple-S is considered an administrator or a fiduciary, I must
use the same standard of review.
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administrator’s “determination was reasonable,” Matias-Correa,
345 F.3d at 12. “Evidence is deemed substantial ‘when it is
reasonably sufficient to support a conclusion.’” Ortega-Candelaria, 755 F.3d at 20 (quoting Cusson v. Liberty Life Assurance Co.
of Boston, 592 F.3d 215, 230 (1st Cir. 2010)). In undertaking this
review, I note that the opinions of treating physicians are not
“automatically grant[ed] ‘special weight.’” Id. (quoting Black &
Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003)). Likewise, “courts may not impose ‘a discrete burden of explanation’ on plan administrators ‘when they credit reliable evidence
that conflicts with a treating physician’s evaluation.’” Id. (quoting Black & Decker, 538 U.S. at 834). Nonetheless, “a plan
administrator ‘may not arbitrarily refuse to credit’ the opinion
of a claimant’s treating physician.” Id. at 25.
According to the Plan, a person is disabled if she is prevented from performing “the material and substantial duties
of [her] regular occupation,” such that she is “not working at
all, or [she is] working” and receiving 20% or less of her predisability earnings.13 Docket No. 27-1, at 26. The Plan’s defini
13. In full, the sentence refers to “the material and substantial duties of
[her] regular occupation and a reasonable employment option offered to [her]
by the employer.” Docket No. 27-1, at 26. However, no party has
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tion of disability thus seems to turn not on whether Carrucini
could work at all, but whether she could do her specific job as
a human resources specialist. And that job, according to her
employer, required continuous sitting and constant computer
use. The relevant question, then, is whether Triple-S had
substantial evidence that Carrucini could perform these
functions.
On administrative appeal, Triple-S bifurcated its analysis of
Carrucini’s claim into mental and physical prongs, asking an
independent physician to consider each. Dr. Marla Rodríguez
assessed Carrucini’s mental health. She relied principally on
the reports of treating mental health professionals indicating
that Carrucini tended to be alert, oriented, and cooperative,
with thought processes that were coherent, logical, and
relevant. Dr. Rodríguez further noted that while Carrucini had
reported problems with concentration and understanding,
Carrucini’s psychiatrist, Dr. Flores Santa, found that Carrucini
had no problems understanding her. Moreover, Carrucini’s self
reporting indicated that she was able to perform daily life
activities and take care of her disabled son. Dr. Rodríguez
discussed any such “reasonable employment option,” and so I focus
solely on the first clause.
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found that an ability to perform these tasks was inconsistent
with a conclusion that Carrucini’s mental state prevented her
from performing her job duties. Dr. Rodríguez did not consider
Carrucini’s diagnoses of fibromyalgia, though some of her
treating physicians believed its origin to be psychological.
Dr. Jaime Foland considered Carrucini’s claim from a
physical perspective. He found that Carrucini had “no physical
conditions supported by the clinical evidence that are functionally impairing.” Docket No. 27-47, at 19. While Dr. Foland
acknowledged that Carrucini suffered from spondylosis, he
did not find it to be severe. Id. Further, he dismissed the idea
that Carrucini’s fibromyalgia could be debilitating by stating
that it “is a treatable condition” that, in his opinion, “should
not be causing impairment.” Id. He noted, moreover, that it the
fibromyalgia might have psychological origins. Id. Dr. Foland
did not consider Carrucini’s diagnosis of carpal tunnel syndrome.
These determinations lacked substantial evidence. The
evidence in the record suggests that the principal cause of
Carrucini’s pain was fibromyalgia. A diagnosis of fibromyalgia
was documented as early as 2008, and was certainly made by
2010; Carrucini’s treating doctors, moreover, believed the
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condition began substantially earlier. All of the treating
physicians that Dr. Foland spoke to believed Carrucini to have
fibromyalgia, and, moreover, they seemed to believe it to be
debilitating. Nonetheless, Dr. Foland gave no weight to these
physicians’ findings for seemingly two reasons: first, because
of a lack of objective evidence in the record; and second,
because “[f]ibromyalgia is a treatable condition.”
To the extent that Dr. Foland found no functional impairment due to a lack of objective tests, his finding cannot be
sustained. As the First Circuit has held in similar circumstances, “findings of chronic pain may not automatically be
dismissed by a benefits administrator for lack of confirmable
symptoms.” Gross v. Sun Life Assurance Co. of Canada, 734 F.3d
1, 22 (1st Cir. 2013). Here, as in Gross, “the doctors who
examined [Carrucini] viewed her symptoms to be consistent
with . . . fibromyalgia” and “uniformly perceive[d] her complaints of pain and limited capacity to be credible.” Id. at 23–24.
As in Gross, then, a lack of objective tests is not a sufficient
basis for denying a disability claim based on fibromyalgia. Dr.
Foland’s second reason for rejecting Carrucini’s claim—that
fibromyalgia is treatable and “should not be causing impairment”—amounts to a rule that fibromyalgia may never be
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disabling. Such a holding is plainly inconsistent with First
Circuit precedent. See, e.g., id.; see also Cusson, 592 F.3d at 226
(holding that a rule stating “that fibromyalgia patients are
never disabled” is “clearly wrong”); Hawkins v. First Union
Corp. Long Term Disability Plan, 326 F.3d 914, 919 (7th Cir. 2003)
(“The fact that the majority of individuals suffering from
fibromyalgia can work is the weakest possible evidence that
[an individual claimant] can.”). Dr. Foland’s conclusion that
Carrucini’s fibromyalgia was not disabling thus lacked
substantial evidence.
Dr. Foland’s error was compounded, moreover, by his
failure to compare Carrucini’s functional capacity to the actual
demands of her job. For example, two of Carrucini’s physicians
diagnosed her with carpal tunnel syndrome, see Docket No. 2746, at 48; Docket No. 27-47, at 18, and stated that she could not
perform repetitive tasks, see, e.g., Docket No. 20-36, at 18–19,
but Dr. Foland, without explanation, failed to include carpal
tunnel or the inability to do repetitive tasks as a functional
impairment. This, despite the fact that Carrucini’s job required
her to work continuously at a computer. See 2 DAN J.
TENNENHOUSE, ATTORNEY’S MEDICAL DESKBOOK § 24:15 (4th
ed.) (noting that “[p]art of the reason for increasing numbers
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Page 20
of [carpal tunnel] injuries is the large number of people who
work at computer terminals”). Similarly, Carrucini’s treating
physicians agreed that she had limitations preventing her from
sitting for long periods of time. See, e.g., Docket No. 20-36, at
18–19. But despite the fact that Carrucini’s job required
constant sitting, Dr. Foland did not address these limitations.
Finally, the bifurcated manner in which Triple-S had
Carrucini’s case reviewed prevented her diagnoses from being
viewed in a holistic manner. Several of Carrucini’s treating
doctors viewed her fibromyalgia as aggravating her depression
or vice-versa. See, e.g., Docket No. 27-47, at 16–17. But Dr.
Foland strongly implied that Carrucini’s fibromyalgia was of
psychological origin, while Dr. Rodríguez didn’t address it at
all. This left no one to consider whether Carrucini’s mental and
physical conditions together caused her any functional
limitations. For these reasons, I find that Triple-S’s decision to
deny Carrucini benefits was arbitrary and capricious.
The next question—which the parties have not addressed—concerns the appropriate remedy. After making a
finding that an administrator’s decision was arbitrary and
capricious, “the court can either remand the case to the
administrator for a renewed evaluation of the claimant’s case,
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Page 21
or it can award a retroactive reinstatement of benefits.” Cook v.
Liberty Life Assurance of Boston, 320 F.3d 11, 24 (1st Cir. 2003).
The First Circuit takes a “flexible approach” to this question,
giving the reviewing court “‘considerable discretion’ to craft a
remedy after finding a mistake in the denial of benefits.”
Buffonge v. Prudential Ins. Co. of Am., 426 F.3d 20, 31 (1st Cir.
2006) (quoting Cook, 320 F.3d at 24). Where the record shows
that the claimant is entitled to benefits, the court may award
them without remanding to the administrator. See id. at 31. In
making this decision, “the principle of ERISA deference does
not deprive a court of its discretion to formulate a necessary
remedy.” Cook, 320 F.3d at 24.
Here, the record before Triple-S showed that Carrucini had
been complaining of chronic pain for years, complaints about
the severity of which Carrucini’s treating physicians without
exception found to be credible. Cf. Maher v. Mass. Gen. Hosp.
Long Term Disability Plan, 665 F.3d 289, 293 n.4 (1st Cir. 2011)
(rejecting the idea that the claimant would have been “able to
fool so many doctors over so many years if there were little or
no serious pain”). She furthermore had a host of other conditions, both mental and physical, at least some of which were
supported by objective tests or history of hospitalization.
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Together, this information—and the lack of evidence reasonably contradicting it—requires a finding that Carrucini was
disabled under the Plan. Cf. Gross, 734 F.3d at 24–25 (“[T]he
sustained and progressive nature of Gross’s complaints, their
facial credibility to the medical practitioners who personally
examined her, and the objective symptoms consistent with
[reflex sympathetic dystrophy]—given the absence of any
method for reaching a conclusive diagnosis—support a finding
of total disability.”).14 I will therefore grant a retroactive award
of benefits to Carrucini.
III.
Conclusion
For the reasons explained above, I GRANT Carrucini’s
motion for summary judgment, Docket No. 28, and necessarily,
then, DENY Triple-S’s cross-motion, Docket No. 19. Accordingly, Triple-S is ORDERED to retroactively award Carrucini
14. I note that despite this language, the Gross and Maher courts went on to
remand, rather than award benefits. See Gross v. Sun Life Assurance Co.
of Canada, 734 F.3d 1, 27–28 (1st Cir. 2013); Maher v. Mass. Gen. Hosp.
Long Term Disability Plan, 665 F.3d 289, 295 (1st Cir. 2011). They did so,
however, because while the medical records in those cases supported
an award of benefits, there also existed in the records video evidence
that arguably contradicted the claimants’ medically-determined
limitations. See Gross, 734 F.3d at 25–28; Maher, 665 F.3d at 295. No such
evidence contradicting the medical record exists here.
CARRUCINI v. TRIPLE-S
Page 23
long-term disability benefits under the Plan, retroactive to
October 12, 2012.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 25th day of March, 2015.
S/ SILVIA CARREÑO-COLL
UNITED STATES MAGISTRATE JUDGE
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