United States Court of Appeals
For the First Circuit
No. 04-2219
No. 04-2252
ANGELA DIGREGORIO,
Plaintiff, Appellant,
v.
HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE COMPANY;
PRICEWATERHOUSECOOPERS LONG TERM DISABILITY PLAN,
Defendants, Appellees.
APPEALS FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS
[Hon. Douglas P. Woodlock, U.S. District Judge]
Before
Torruella, Lipez, and Howard, Circuit Judges.
Stephen L. Raymond for appellant.
David B. Crevier, with whom Theodore F. Glockner was on brief,
for appellees.
September 8, 2005
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
1
Hartford and the Plan filed a notice of cross-appeal but
acknowledge in their answering brief that they do not challenge any
of the district court's factual findings or legal conclusions, and
that they seek affirmance of the district court's judgment. We
therefore deem all arguments on the cross-appeal to be forfeited
and dismiss the cross-appeal, No. 04-2252. DiGregorio's February
23, 2005 motion to order the cross-appeal "denied as waived" is
denied as moot. See 1st Cir. R. 27(c).
-2-
I.
The facts of this case are set forth in detail in the
district court's opinion. See DiGregorio v. PricewaterhouseCoopers
Long Term Disability Plan, No. 03-11191, 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]
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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
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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
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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
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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
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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 from
Dr. Jupiter.
Dr. Jupiter's letter to DiGregorio of February 6, 2001
stated that "electrical evaluation of your hand and wrist . . .
shows substantial and serious compression of the median nerves in
the carpal tunnel. . . . I believe that the problem can affect
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your ability to function and that you have at least for the present
an ongoing disability as a result of this." His treatment note of
July 31, 2001 stated that "an EMG and nerve conduction study . . .
afforded a compressive neuropathy in the median nerve. This
interferes with [DiGregorio's] ability to function. She remains
disabled because of this and will do so on a continued basis unless
intervention proves successful. . . . Her prognosis is guarded."
Dr. Jupiter's letter to DiGregorio's attorney of October 12, 2001
stated: "An EMG and nerve conduction study confirm[] that
[DiGregorio] still has dysfunction of her nerve. On the basis of
this and her symptoms she continues to be disabled in her
secretarial line of work and feels that she is unable to perform
bimanual tasks in any form of work."
Although DiGregorio did not request copies of any
documents considered during Hartford's review of her appeal in her
November 8, 2001 letter, she reiterated her position that
Hartford's failure "to provide her entire claim file in response to
her request for copies of documents 'pertinent' to the denial of
her claim eviscerates her right to a full and fair review of this
claim under ERISA."
Hartford upheld its termination of DiGregorio's claim for
LTD benefits by letter on December 12, 2001, based on its
consideration of "Plan language and all documents contained in
[DiGregorio's] claim file," including the additional information
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DiGregorio had submitted with her appeal letter. Hartford first
noted that DiGregorio did not appear to be under the regular care
of a physician, as required by the Plan. Hartford then addressed
DiGregorio's disability status, explaining that "[t]he testing and
other medical documentation supplied does support an inability to
use her hands in a repetitive manner. However, there is no medical
documentation to support her inability to perform an occupation
that does not require repetitive hand motion," such as any of the
four "Clerk" occupations identified in the March 22, 2001
Employability Analysis Report.
Hartford also indicated that it had reviewed an
additional document not submitted by DiGregorio, namely, a "Report
from Dr. Jesse Jupiter, received in our office 12/06/01." Hartford
explained:
In an attempt to further clarify Ms.
Di[Gre]gorio's functional capacity, [a
registered nurse employed by Hartford] sent a
letter to Dr. Jupiter with specific questions
related to her disability and functional
ability. When asked if he agreed with the
restrictions identified by Dr. Howard of
04/11/00, Dr. Jupiter responded affirmatively.
If you recall, Dr. Howard stated that Ms.
Di[G]regorio is capable of full-time work in
an occupation that does not require repetitive
use of her hands.
E. Proceedings in District Court
On October 1, 2003, DiGregorio filed an amended complaint
in federal district court under ERISA § 502(a)(1)(B), 29 U.S.C.
§ 1132(a)(1)(B), which empowers a plan participant or beneficiary
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to bring a civil action "to recover benefits due to [her] under the
terms of [her] plan, to enforce [her] rights under the terms of the
plan, or to clarify [her] rights to future benefits under the terms
of the plan." In her complaint, DiGregorio alleged that she
qualified for LTD benefits under the Plan's definition of Total
Disability, and that Hartford had erred in upholding its decision
to terminate her benefits. DiGregorio also alleged that Hartford
had not "afford[ed] [her] a reasonable opportunity . . . for a full
and fair review" of her claim, as required by ERISA § 503(2), 29
U.S.C. § 1133(2), and its implementing regulations, because
Hartford had failed to provide her with a copy of her entire claim
file upon request. DiGregorio sought relief in the form of a
declaratory judgment of entitlement to LTD benefits under the Plan;
retroactive and prospective reinstatement of benefits; attorney's
fees and costs; and "such further, necessary, or proper relief as
[the court] deems just and equitable in the circumstances."
Having obtained a copy of her entire claim file during
litigation, DiGregorio moved for judgment on the administrative
record on June 11, 2004. DiGregorio did not seek to introduce any
evidence outside of the administrative record for consideration by
the district court. As an alternate prayer for relief, however,
DiGregorio sought a remand of her benefits claim to Hartford for an
opportunity to supplement the administrative record. Hartford and
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the Plan cross-moved for summary judgment on June 21, 2004.2
During a hearing on August 4, 2004, the parties agreed to the
court's suggestion that it treat their cross-motions for summary
judgment as "a case stated or trial on the record itself," thereby
permitting the court to make findings of fact instead of granting
inferences to each non-movant in turn.
The district court awarded judgment to Hartford and the
Plan on DiGregorio's claim of entitlement to benefits on August 9,
2004. In a written Memorandum and Order, the court reviewed de
novo Hartford's decision to uphold its termination of DiGregorio's
benefits. DiGregorio, 2004 U.S. Dist LEXIS 15485, at *41. It
held that "given DiGregorio's underlying failure to adduce any
affirmative evidence supporting her contention that she was
disabled as to any occupation, the opinions of Dr. Howard and Dr.
Jupiter are fatal to [her] claim. Accordingly, I conclude that
Hartford[] correctly determined that DiGregorio was not entitled to
continued LTD benefits." Id. at *60-61. The court did not reach
the question of whether DiGregorio was otherwise unentitled to
benefits because she did not meet "the Plan's requirement that she
be under the 'regular care' of a physician." Id. at *61 n.25.
In a brief discussion at the end of its lengthy opinion,
the court separately addressed DiGregorio's argument that Hartford
2
Neither Hartford nor the Plan sought a remand on the ground
that DiGregorio had failed to exhaust her administrative remedies.
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and the Plan had deprived her of a reasonable opportunity for a
full and fair review of her claim in violation of ERISA § 503(2) by
failing to provide her with a copy of her entire claim file upon
request. "Even assuming that DiGregorio is correct that she was
entitled to her complete file under [ERISA] § 503," the court
stated, "she must additionally demonstrate that she was somehow
prejudiced by Hartford's failure to provide the file," which
DiGregorio had obtained during the litigation. Id. at *62. The
court noted that DiGregorio "contends that" if she had received a
copy of her entire claim file, "she would have provided evidence
that she was under the regular care of a physician, evidence that
she suffered from pain and other psychological deficits associated
with her condition, and some further vocational expertise as to
available jobs." Id. at *63, n.27. The court concluded, however,
that DiGregorio's argument that "she would have supplemented [the
administrative record] with further evidence to support her claim"
if she had been able to review her entire claim file was
post hoc rationalization. If DiGregorio had
additional information that could have altered
Hartford's decision, there was no reason she
could not have submitted it along with the
evidence she submitted during the appeals
process. . . . I note she has not alluded to
any evidence that she had or has additional
information that would have changed Hartford's
decision to deny her claim. Thus, I conclude
that she was not denied a full and fair review
of her claim.
Id. at *63 (citation omitted).
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DiGregorio timely appealed.
II.
A. Scope and Standard of Review
DiGregorio raises a narrow issue on appeal. She does not
challenge the factual findings and legal conclusions set forth in
the district court's nearly fifty-page opinion relating to the
merits of her claim of entitlement to benefits based on the
existing administrative record, reached upon de novo review of
Hartford's final decision. Nor does DiGregorio seek review of any
decision by the court relating to the admission of extra-record
evidence, having made no attempt to introduce any such evidence
before the district court. DiGregorio argues only that the court,
instead of granting judgment in favor of Hartford and the Plan,
should have remanded her claim to Hartford for supplementation of
the record because Hartford failed to provide her with a copy of
her entire claim file during its internal review process.
The scope of our review therefore is limited to the
questions of whether the district court properly conditioned remand
on a showing of prejudice and, if so, whether the district court
correctly determined that DiGregorio had not made the requisite
showing. Whether a remand based on Hartford's failure to disclose
the complete claim file upon request requires a showing of
prejudice is a legal question that we review de novo. Reich v.
John Alden Life Ins. Co., 126 F.3d 1, 6 (1st Cir. 1997). The
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court's determination that DiGregorio did not show prejudice, by
contrast, is a factual conclusion that we review only for clear
error. Id.
B. DiGregorio's Entitlement to Review "Pertinent Documents"
"ERISA sets certain minimum requirements for procedures"
that a plan must implement for use "when a plan administrator
denies a claim for benefits." Halpin v. W.W. Grainger, Inc., 962
F.2d 685, 688 (7th Cir. 1992). Pursuant to ERISA § 503, 29 U.S.C.
§ 1133,
[i]n accordance with regulations of the
Secretary [of Labor], every employee benefit
plan shall--
(1) provide adequate notice in writing
to any participant or beneficiary whose claim
for benefits under the plan has been denied,
setting forth the specific reasons for such
denial, written in a manner calculated to be
understood by the participant, and
(2) afford a reasonable opportunity to
any participant whose claim for benefits has
been denied for a full and fair review by the
appropriate named fiduciary of the decision
denying the claim.
These baseline procedural protections "insure that when a claimant
appeals a denial to the plan administrator, [she] will be able to
address the determinative issues and have a fair chance to present
[her] case." Halpin, 962 F.2d at 689. At the same time, they
permit the resolution of many claims disputes without "having to
resort to the expense and delay of the courts." Weaver v. Phoenix
Home Life Mut. Ins. Co., 990 F.2d 154, 157 (4th Cir. 1993).
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In order to implement the "full and fair review"
requirement of ERISA § 503(2),3 the Secretary of Labor adopted
regulations in 1977 requiring "[e]very plan [to] establish and
maintain a procedure by which a claimant . . . may (ii) Review
pertinent documents" upon a plan administrator's denial of a claim
for benefits. 29 C.F.R. § 2560.503-1(g)(1) (1977) (amended 2000).
In the Preamble to the regulation, the Department of Labor
expressed its view that "[a]s part of the review the participant
must be allowed to see all plan documents and other papers which
affect the claim," and that "plan procedures for review of claim
denials must include the right of a claimant to . . . review
pertinent documents relating to the denial." 42 Fed. Reg. 27426,
27426-27 (May 27, 1977).4
3
On appeal, DiGregorio does not challenge the defendants'
compliance with the notice requirements of ERISA § 503(1), 29
U.S.C. § 1133(1), and its implementing regulations.
4
In 2000, the Department of Labor amended 29 C.F.R.
§ 2560.503-1 to require that a plan's claim denial and review
procedures must, among other things, "[p]rovide that a claimant
shall be provided, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other
information relevant to the claimant's claim for benefits," 29
C.F.R. § 2560.503-1(h)(2)(iii) (2000) (emphasis added). Among the
materials defined as "relevant" by 29 C.F.R. § 2560.503-1(m)(8)
(2000) are those "relied upon in making the benefit determination,"
as well as those "submitted, considered, or generated in the course
of making the benefit determination, without regard to whether
[they were] relied upon in making the benefit determination."
(Emphasis added).
The parties agree that DiGregorio's claim is not governed by
the regulation as amended in 2000 but by the original version
adopted in 1977. DiGregorio filed her claim for benefits under the
Plan before the amended regulation took effect on January 1, 2002.
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"The opportunity to review . . . pertinent documents is
critical to a full and fair review, for by that mechanism the
claimant has access to the evidence upon which the decision-maker
relied in denying the claim and thus the opportunity to challenge
its accuracy and reliability." Ellis v. Metropolitan Life Ins.
Co., 126 F.3d 228, 237 (4th Cir. 1997). As one court has
elaborated, because judicial review of claim denials is ordinarily
limited to the administrative record,
[t]he Plan's internal review process may be
the claimant's last genuine opportunity to
influence the final decision, to supplement
the record in preparation for judicial review,
or to correct any errors in the existing
record. Meaningful participation in this
internal review process therefore requires
that the claimant have an opportunity to
See 29 C.F.R. § 2560.503-1(o). DiGregorio argues, however, that
the pre-amendment regulation requires plans to provide the same
materials as those specified in the amended regulation because the
Department of Labor has consistently interpreted the 1977 version
of the regulation as contemplating that "claimants must be provided
access to all of the information present in the claims record,
whether or not that information was relied upon by the plan in
denying the claim and whether or not that information was favorable
to the claimant." 65 Fed. Reg. at 7024b, 70252 (Nov. 21, 2000).
DiGregorio also points out that Hartford acknowledged in its denial
letter of April 18, 2001 that it had "considered [her] claim file
as a whole" in deciding to terminate DiGregorio's LTD benefits.
Because we assume, without deciding, that Hartford was
obligated to provide DiGregorio with her entire claim file, we need
not determine the effect of the 2000 amendment on the Plan's
obligations under ERISA § 503 and Hartford's duties as Plan
administrator. Nor do we need to address Hartford's arguments that
(1) a plan administrator commits no procedural violation so long as
it substantially complies with the procedural requirements imposed
on ERISA plans by regulation and (2) its provision of two documents
from DiGregorio's claim file, the Employability Analysis Report and
Dr. Howard's Evaluation, constitutes substantial compliance.
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review the relevant documents in the claim
file so the claimant may submit any additional
documents, correct any errors in the record,
point to any favorable evidence that would
tend to support the claim, fully understand
the reasons for the decision that is being
appealed, and to otherwise prepare an informed
response to that decision.
Palmer v. Univ. Med. Group, 994 F. Supp. 1221, 1240 (D. Or. 1998).
DiGregorio maintains that Hartford's failure to disclose
her complete claim file upon request deprived her of an opportunity
for full and fair review as required by ERISA § 503(2). Following
the district court's approach, we will assume for the purposes of
our decision that DiGregorio was entitled to see her entire claim
file. See DiGregorio, 2004 U.S. Dist LEXIS 15485, at *62.
C. Prejudice
Although the district court assumed that "DiGregorio
. . . was entitled to her complete file under [ERISA] § 503," it
ultimately concluded that she "was not denied a full and fair
review of her claim" because she failed to "demonstrate that she
was somehow prejudiced by Hartford's failure to provide the file."
DiGregorio, 2004 U.S. Dist LEXIS 15485, at *62 (footnote and
citation omitted). On appeal, DiGregorio disputes the conclusion
that a showing of prejudice is required to demonstrate a violation
of ERISA's "full and fair review" requirement. She also argues
that, in any event, she was prejudiced by Hartford's failure to
disclose the complete claim file upon request.
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1. Propriety of Prejudice Requirement
In Terry v. Bayer Corp., 145 F.3d 28, 39 (1st Cir. 1998),
the case relied upon by the district court for its prejudice
requirement, we upheld a district court's denial of a plaintiff's
claim of entitlement to benefits in part because the claimant
failed to "present[] any evidence that implies that a different
outcome would have resulted" if the plan administrator's notice of
denial of his claim had "been in formal compliance with the
regulations" requiring plans to specify the procedures perfecting
a claim and for obtaining review of an adverse decision.
Terry, in turn, relied on our earlier decision in
Recupero v. New Eng. Tel. & Tel. Co., 118 F.3d 820, 825 (1st Cir.
1997), in which we affirmed the district court's denial of a
plaintiff's similar claim of entitlement to benefits despite the
court's conclusion that the defendant's "denial letters . . . were
insufficient as a matter of law" given ERISA's statutory and
regulatory requirements for the provision by plan administrators of
notice of the procedures for obtaining review of the denial of a
claim. In Recupero, we held that the district court properly
denied the plaintiff relief "for [defendant's] failure to conform"
to the procedural requirements of ERISA § 503 where "[t]he district
court determined that Recupero had not proffered evidence
sufficient to support a finding of prejudice in any relevant
sense." Id. at 840; cf. Orndorf v. Paul Revere Life Ins. Co., 404
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F.3d 510, 520 (1st Cir. 2005) (noting that it may be appropriate
for the court to consider "evidence outside the administrative
record" in assessing a claim of "prejudicial procedural
irregularity in the ERISA administrative review procedure"
(emphasis added)).
DiGregorio attempts to distinguish her case from these
precedents solely on the ground that the procedural irregularity in
Terry and Recupero involved a plan administrator's failure to
provide the requisite notice of the steps required to perfect a
claim for benefits or seek review of the denial of a claim, while
her case involves Hartford's more egregious failure to provide
documents for DiGregorio's review in preparation of her appeal
letter.
We find the distinction unpersuasive in this case.
Nothing in either Terry or Recupero explicitly limits the prejudice
requirement to claims of defective notice under ERISA § 503(1), as
opposed to claims of failure to disclose a complete claim file
under § 503(2). Nor does the fact that the appellants in Terry and
Recupero sought a grant of benefits on appeal, rather than the more
limited request for a remand to supplement the administrative
record, create a meaningful distinction between the cases for
purposes of the prejudice requirement. DiGregorio is essentially
seeking a second chance, based on Hartford's failure to disclose
her complete claim file the first time around, to show that she is
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entitled to benefits. Under these circumstances, as a basis for a
remand, the district court correctly required DiGregorio to
demonstrate a connection between Hartford's failure to disclose the
complete file and her inability to receive from the plan
administrator a full and fair review of her claim to benefits.
2. Application of Prejudice Requirement
To be entitled to a remand, DiGregorio must "show
prejudice in a relevant sense." Recupero, 118 F.3d at 840. In
other words, she must show that as a result of Hartford's failure
to disclose her complete claim file, she did not understand the
evidence that she had to provide to dispute Hartford's conclusion
that she was not entitled to benefits.
DiGregorio contends that if she had been able to review
her entire claim file while she was preparing her appeal letter,
she "would have provided evidence that she was under the regular
care of a physician, evidence that she suffered from pain and other
psychological deficits associated with her condition, and some
further vocational expertise as to available jobs." Id. at *63
n.27. The court dismissed this contention as "post hoc
rationalization," noting that "[i]f DiGregorio had additional
information that could have altered Hartford's decision, there was
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no reason she could not have submitted it along with the evidence
she submitted during the appeals process." Id.5
Under the terms of the Plan, DiGregorio had to show that
her bilateral carpal tunnel syndrome rendered her unable to hold
"any occupation . . . for which [she was], or may be, qualified by
education, training or expertise." The documents Hartford did
provide to DiGregorio in response to her initial request for
documents clearly revealed Hartford's belief that DiGregorio could
perform other occupations for which she was or could be qualified
despite her bilateral carpal tunnel syndrome. In her appeal
letter, DiGregorio challenged the assumptions upon which Hartford's
Employability Analysis Report was based, as well as the accuracy of
Dr. Howard's recommendation. DiGregorio also submitted the opinion
of a different physician, Dr. Jupiter. Yet Dr. Jupiter's opinion
merely confirmed that DiGregorio could not perform her own
occupation as a secretary, and that DiGregorio "feels that she is
unable to perform bimanual tasks in any form of work." DiGregorio
does not challenge the district court's determination that the
5
In her motion for judgment on the administrative record,
DiGregorio argued that she suffered prejudice from Hartford's
failure to notify her in its denial letter that it did not consider
her to be under the regular care of a physician. She argued that
if she had been aware of this alternate ground for Hartford's
denial of her claim, she would have submitted proof that she was
under the regular care of a physician with her appeal letter to
Hartford. The court upheld Hartford's decision to uphold its
denial of DiGregorio's claim on the alternate ground that she did
not meet the Plan's definition of Total Disability.
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medical reports of both Dr. Howard and Dr. Jupiter, DiGregorio's
own physicians, were "fatal to [her] claim." Id. at *60-61.
In short, DiGregorio has not shown "prejudice in a
relevant sense." Recupero, 118 F.3d at 840. She has not
demonstrated that Hartford's failure to disclose her complete file
upon request prevented her from submitting evidence necessary to
dispute the denial of her claim for benefits. Nor has DiGregorio
shown that the refusal to disclose the complete claim file had any
impact on her "[m]eaningful participation in [the] internal review
process" or otherwise impaired her ability to "prepare an informed
response to [Hartford's] decision." Palmer, 994 F. Supp. at 1240.
The district court's conclusion that DiGregorio did not make the
requisite prejudice showing therefore was not clearly erroneous.
Absent such a showing, the district court properly denied
DiGregorio's request for a remand to Hartford of her benefits claim
for supplementation of the record. Therefore, the district court's
judgment is affirmed.
So ordered.
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