Ortega-Candelaria v. Johnson & Johnson , 755 F.3d 13 ( 2014 )

United States Court of Appeals
For the First Circuit
No. 13-1564
ROLANDO ORTEGA-CANDELARIA,
Plaintiff, Appellant,
v.
JOHNSON & JOHNSON; MEDICAL CARD SYSTEM, INC.,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. José Antonio Fusté, U.S. District Judge]
Before
Torruella, Baldock,* and Kayatta,
Circuit Judges.
Pedro J. Landrau-López, for appellant.
Lourdes C. Hernández-Venegas, with whom Elizabeth Pérez-
Lleras, Shiara L. Diloné-Fernández and Schuster Aguiló LLP, were on
brief for appellees.
June 16, 2014
*
Of the Tenth Circuit, sitting by designation.
TORRUELLA, Circuit Judge. Plaintiff-Appellant Rolando
Ortega-Candelaria ("Ortega") appeals the district court's dismissal
of his claims under the Employee Retirement Income Security Act
("ERISA"), 29 U.S.C. §§ 1001-1461. Before the district court,
Ortega sought judicial review of the decision to terminate payment
of disability benefits to him under Johnson & Johnson's Long-Term
Disability Plan (the "Plan"). Ortega requested a judgment
restoring his terminated benefits and ordering payment of past
benefits. The district court dismissed Ortega's claims with
prejudice.
On appeal, Ortega argues that Johnson & Johnson and
Medical Card System, Inc. ("MCS") (collectively, the "Appellees")
arbitrarily and capriciously terminated his disability benefits.
Ortega contends that the Appellees erroneously credited an
examination by a physical therapist over the opinion of his
treating physician. Given the substantial record evidence
supporting the Appellees' determination, we find that the decision
to terminate Ortega's benefits did not constitute an abuse of
discretion and was neither arbitrary nor capricious. We affirm.
I. Background
A. The Plan
Johnson & Johnson sponsors the Plan to provide long-term
disability benefits for its employees and the employees of its
affiliated companies. Ortega received coverage under the Plan
-2-
while working in Puerto Rico as an electrician for Ortho Biologics
LLC, a subsidiary of Johnson & Johnson.
In order to be eligible for plan benefits, a participant
must be considered "totally disabled." During the first twelve
months of an injury or sickness, a plan participant must be unable
to perform the essential functions of his or her "regular job" in
order to qualify as "totally disabled." If the injury or sickness
lasts longer than twelve months, the participant must remain
completely unable "to do any job" -- "with or without reasonable
accommodation," and "for which the Participant is (or may
reasonably become) qualified by training, education, or experience"
-- in order to continue to be classified as "totally disabled."
Pursuant to the Plan, the plan administrator maintains
"the right to conduct evaluations of a Participant's medical status
and eligibility for benefits" at any time while a claim is pending
or the participant is receiving benefits.1 The Plan further grants
the plan administrator the sole discretion "to construe and
interpret" the Plan's terms and the sole discretion to determine
1
As defined in the Plan, and as used herein, the term "plan
administrator" encompasses both the Johnson & Johnson Pension
Committee ("Pension Committee") and MCS, the claims services
organization retained by Johnson & Johnson to provide
administrative services related to the Plan. "In the event of a
denial or limitation of benefits," a participant may appeal to MCS.
If MCS upholds the original denial of benefits, the participant may
appeal a second time to the Pension Committee. A participant may
commence a lawsuit only after a final decision has been rendered on
this second appeal.
-3-
whether there exist grounds for termination of a participant's
benefits.2 Under the Plan, such grounds include a claimant's
failure to cooperate with respect to any procedure or evaluation in
connection with the Plan.3
A participant making a claim for benefits under the Plan
must provide "all information necessary to evaluate his or her
medical condition and functional capacity." At the plan
administrator's discretion, "the evaluation may include medical
examination(s) by a Plan Provider." Further, "[o]ne or more
Independent Medical Examination(s) (IME) and Functional Capacity
2
In relevant part, Article VII of the Plan states that the plan
administrator "has the sole authority to . . . [e]xercise its
discretion to determine eligibility for benefits, to construe and
interpret the provisions of the Plan and to render conclusive and
binding decisions and determinations based thereon."
3
In the section titled "Evaluation of Participant's Medical
Status," the Plan states that a participant making a claim is
required to "cooperate . . . in the evaluation of the Participant's
medical status." "Failure or refusal by the Participant to
cooperate in the medical evaluation . . . shall constitute grounds
for terminating benefits under the Plan."
In a section titled "Exclusions from Payment of Benefits," the
Plan further states, in relevant part, that:
Notwithstanding any other provision of this Plan, in no
event shall a Participant be considered Totally Disabled
or remain Totally Disabled, and no benefit shall be
payable under this Plan . . . on or after the date a
Participant . . . fails or refuses to cooperate with
respect to the evaluation of his/her Total Disability or
continuing Total Disability or with respect to any
procedure, evaluation, investigation or audit in
connection with this Plan . . . .
-4-
Examination(s) (FCE) may be required at any time during the claim
evaluation process."
B. Ortega's Claim Under the Plan
As an electrician for Ortho Biologics LLC, Ortega held a
"mostly active" job that required "bending, walking, climbing,
[and] working [in a] standing position for long period[s] of time,"
and which required him to "pull, push, lift/carry and squat" on a
"routine basis."
Ortega alleges that since 2002, he has been unable to
work due to constant pain caused by vertebral herniations,
degenerative scoliosis, osteoarthritis, and radiculopathies. He
also claims to suffer from anxiety, panic disorder, and depression.
As a result of these conditions, Ortega went on non-occupational
disability leave, and he began receiving short-term disability
benefits on October 28, 2002. Subsequently, on June 3, 2003,
Ortega submitted his first claim for long-term disability benefits,
in which he asserted that he was unable to bend or walk,
experienced consistent pain in his legs and back, and suffered from
anxiety, panic attacks, and depression.
Shortly thereafter, MCS received two "Attending Physician
Statements" in support of Ortega's claim. The first of these
statements addressed Ortega's mental and emotional condition,
concluding that Ortega suffered from panic disorder as well as
"major depression." The second statement, regarding Ortega's
-5-
physical ailments, specified that he suffered from radiculopathies,
herniation of lumbosacral discs, degenerative scoliosis, and
osteoarthritis.
Ortega's claim for long-term disability benefits for his
physical condition was approved on July 23, 2003, but Ortega was
notified that such benefits would apply retroactively beginning
from June 24, 2003. Ortega's claim for benefits due to his mental-
health symptoms, however, was denied. In its subsequent
confirmation of the approval of Ortega's physical claim, MCS
advised Ortega that he was required to undergo regular treatment
with a specialist and that his case would be reevaluated
periodically by MCS's Medical Committee to determine his continued
eligibility for long-term disability benefits.
On October 20, 2003, MCS requested that Ortega provide a
copy of the medical records held by his attending physicians at the
time in order to determine his continued eligibility for long-term
disability benefits. Thereafter, on October 30, 2003, Ortega
participated in a functional capacity evaluation ("FCE") conducted
by Rafael E. Seín, M.D. ("Dr. Seín"), a physiatrist, or
rehabilitation physician.
Dr. Seín reported that Ortega: "demonstrated a very
restricted" -- or "sub-minimal" -- "effort during the weighted and
non-weighted activities, with a more mental involvement that
aggravates his physical condition"; frequently shifted weight on
-6-
either leg despite his major pain symptoms being related to his
right leg only; "demonstrated inconsistency" on a hand-grip test;
and refused to perform some activities due to fear of being
injured. On that basis, Dr. Seín recommended an independent
psychiatrist evaluation. He concluded that Ortega had the physical
capacity for sedentary work, but with restrictions on prolonged
standing, sitting, and walking.
In contrast, in progress notes dated November 4, 2003,
Ortega's attending physician -- Oscar E. Ramos Román, M.D.
("Dr. Ramos") -- stated that Ortega was permanently disabled from
work, noting that he still suffered from severe neck and back pain,
scoliosis, anxiety, and depression. On November 25, 2003, upon
reviewing Dr. Ramos's progress notes and the results of the FCE,
MCS's independent medical consultant -- José Ocasio, M.D.
("Dr. Ocasio") -- recommended extending Ortega's benefits, but
further recommended that Ortega be reevaluated six months later.
On April 6, 2004, Ortega underwent a second FCE, again
conducted by Dr. Seín. Following the examination, Dr. Seín's
report stated that Ortega demonstrated very inconsistent efforts
throughout the FCE and that he refused to attempt several
activities, both weighted and non-weighted, which he had performed
in the prior FCE. Dr. Seín again concluded that Ortega had the
functional capacity for sedentary activities, albeit with
restrictions.
-7-
On April 28, 2004, after evaluating Dr. Seín's report,
Dr. Ocasio recommended denying Ortega's long-term disability
benefits due to his lack of cooperation during the second FCE.
However, Dr. Ocasio later reconsidered, and he ultimately
recommended approval of the benefits. As before, Dr. Ocasio
further recommended that Ortega undergo reevaluation in six months.
On August 19, 2004, MCS informed Ortega that, because
Dr. Ramos's progress notes continued to mention Ortega's mental
health, MCS was reevaluating the denial of his long-term disability
benefits regarding his mental and emotional state. Luis E. Cánepa,
M.D. ("Dr. Cánepa"), reviewed a copy of the progress notes
regarding Ortega's mental health and concluded that Ortega's
emotional conditions seemed moderate in severity. Dr. Cánepa
further recommended that Arlene Rivera-Mass, M.D. ("Dr. Rivera"),
a psychiatrist, perform an independent medical evaluation of
Ortega.
Following this psychiatric medical evaluation conducted
on October 13, 2004, Dr. Rivera concluded that, while Ortega
presented symptoms compatible with panic and mood disorder, it
"seem[ed] that there was a frank exaggeration of symptoms." For
example, Dr. Rivera noted that Ortega "claimed extremely poor
memory but did not present in the interview [with] such
difficulty." Dr. Rivera opined that "the information he gave
during the interview is unreliable," and that as a result, further
-8-
investigation should occur in order to correctly diagnose Ortega's
mental and emotional symptoms. After reviewing Dr. Rivera's
conclusions, Dr. Cánepa recommended denying Ortega long-term
disability benefits based on his mental state.
C. The FCE Conducted by Javier Espina on November 16, 2004
On November 16, 2004, Ortega underwent a third FCE, which
was conducted by Javier Espina ("Espina"), a physical therapist.
Espina said that Ortega would only be asked to perform activities
he felt capable of completing; Ortega could stop any test that
caused him pain, if he so desired. Espina further instructed
Ortega to exert his best efforts in attempting each activity.
Following the FCE, Espina concluded that Ortega's "symptomatic
reports and behavior are out of proportion to the objective
physical findings and the identified pathology."
Specifically, Espina reported that Ortega: "did not
complete all test activities"; "declined all lifting, carrying,
pushing, pulling and climbing activities," stating that he did not
want to risk further injury; and "demonstrated a consistent sub-
maximal effort throughout this evaluation." For example, Espina's
report observed that Ortega "declined the (Right Leg) Sitting Leg
Raising" test, stating that "he couldn't flex his Right Knee,"
although the testing center's "video clearly shows that Mr. Ortega
[was] able to Sit and Flex his Right Knee" while seated in the
waiting room.
-9-
Espina further determined that Ortega "demonstrated a
regional, non-specific" testing pattern "that is not consistent
with an organic pain syndrome." Ortega's scores on testing
protocols "indicat[ed] that there is a non-organic component to his
pain, medical impairment and disability." During this FCE, Ortega
passed only three out of twenty-one "validity criteria," which are
used to objectively determine whether a patient is honestly trying
his or her best to complete the various physical tasks required for
the evaluation. According to Espina, this fourteen-percent pass
rate "suggests very poor effort or voluntary sub maximal effort,
which is not necessarily related to pain, impairment or
disability."4
4
Espina's report notes that a person's "Validity Profile is
comprised of a cohort of individual tests that collectively help
determine whether or not the patient is exerting their best effort
during all of the FCE tests." Failing the test indicates that the
patient has "not exerted their best effort." Because "the patient
is not asked to perform tasks for which they do not have the
physical ability" and "the test data should reveal" if the patient
does not have such ability, "then the only reason for not passing
the overall Validity Profile is that the patient was not motivated
to cooperate with the evaluation process and exert their best
effort." According to the report, "failing the Overall Validity
Profile is viewed as a voluntary act of non-compliance with the
testing process and the professionals who requested the test."
With respect to the number of validity criteria passed, a rate
of 90-100% indicates "Excellent Effort," 80-89% indicates "Good
Effort," 70-79% indicates "Fair Effort," 60-69% indicates "Poor
Effort," and less than 60% indicates "Very Poor Effort." Ortega
passed only 14% of the validity criteria, leading Espina to
conclude that his performance was "Invalid" and demonstrated "Very
Poor Effort."
-10-
Espina observed that "Ortega's movement patterns improved
significantly by distraction" when compared to the ability he
demonstrated during direct observation. Such a finding suggests
that Ortega was "attempting to control the test results to
demonstrate more pain and disability than [were] actually present."
As one example, in evaluating Ortega's gait, Espina noted that
Ortega's movements while walking exhibited a "poor correlation with
the pain rating" and that his "behavior is inappropriate." In
concluding his detailed analysis, Espina reported that Ortega's
behavior and physical performance were not consistent with his
stated symptoms and alleged disability. Instead, Espina concluded
that Ortega was, in fact, exaggerating his symptoms and
disabilities.5
D. The Termination of Ortega's Benefits
On November 22, 2004, after reviewing Espina's report and
Dr. Ramos's updated progress notes, Dr. Ocasio recommended denying
Ortega long-term disability benefits due to his lack of cooperation
during the third FCE. Accordingly, MCS notified Ortega that,
pursuant to the Plan's terms, Ortega's lack of cooperation in the
evaluation process justified the termination of his long-term
disability benefits.
5
The report states that "The Movement Patterns and Behavior Are
Not Consistent with the Symptoms and Disability," and concludes
that "True Symptom/Disability Exaggeration Exists."
-11-
On January 12, 2005, Ortega appealed that decision. He
attached a letter dated December 10, 2004, in which Dr. Ramos
concluded that, in his professional opinion, Ortega was "totally
and permanently disabled to work." On January 19, 2005, after
reviewing Ortega's records -- including the updated progress notes
from all of Ortega's attending physicians -- Dr. Ocasio
nevertheless recommended the denial of Ortega's appeal because
Ortega presented no new evidence that would support a different
recommendation.
Ortega requested a second appeal of his claim on
February 24, 2005. He attached Dr. Ramos's signed medical
certificate, which stated that Ortega's physical condition was
progressive, he still suffered from severe back pain, and he was
incapable of performing the tests requested by MCS.
On March 20, 2005, after reviewing Ortega's second
appeal, the Johnson & Johnson Disability Review Committee upheld
the decision to terminate his long-term disability benefits for
failing to cooperate with the evaluations of his continuing
disability. Additionally, in its review of Ortega's record, the
Disability Review Committee found no circumstances justifying or
explaining Ortega's lack of cooperation or his exaggeration of
symptoms. Lastly, the committee found that Ortega himself failed
to provide any explanation for his "lack of cooperation/compliance
in completing the tests that were included in the FCE."
-12-
E. Procedural History
Before the district court, Ortega argued that the
Appellees arbitrarily and capriciously denied his benefits due
under ERISA, and he requested a judgment ordering the reinstatement
of those benefits as well as the retroactive payment of past
benefits.6 After granting Appellees' motion to proceed with the
matter as an administrative appeal, the district court granted
Appellees' motion for judgment on the administrative record and
dismissed Ortega's claim with prejudice on March 26, 2013.
In so doing, the district court held that the record
provided the plan administrator ample basis for finding that Ortega
did not cooperate fully during the FCE held on November 20, 2004,
and thus Appellees did not act arbitrarily and capriciously in
terminating Ortega's benefits. This appeal followed.
II. Analysis
We generally review the denial of benefits under an ERISA
plan de novo. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S.
101, 115 (1989); Gross v. Sun Life Assurance Co. of Can., 734 F.3d
1, 11 (1st Cir. 2013) (stating that "[t]he default standard for
reviewing [ERISA] benefits decisions . . . is de novo"). However,
where the plan grants the plan administrator or another fiduciary
the discretionary authority to construe the terms of the plan or to
6
Ortega also sought an award of costs and attorney's fees, plus
any other available damages and remedies.
-13-
determine a participant's eligibility for benefits, as is the case
here, we apply a deferential standard of review, upholding the
administrator's decision "unless it is 'arbitrary, capricious, or
an abuse of discretion.'" See Cusson v. Liberty Life Assurance Co.
of Bos., 592 F.3d 215, 224 (1st Cir. 2010) (quoting Gannon v.
Metro. Life Ins. Co., 360 F.3d 211, 213 (1st Cir. 2004).
This deferential standard of review, however, is not
entirely without teeth -- it requires that a determination by a
plan administrator "must be 'reasoned and supported by substantial
evidence.'" Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack
Anesthesia Assocs. Long Term Disability Plan, 705 F.3d 58, 62 (1st
Cir. 2013) (quoting D & H Therapy Assocs., LLC v. Bos. Mut. Life
Ins. Co., 640 F.3d 27, 35 (1st Cir. 2011)). "In short," such a
determination "must be reasonable." Id. (citing Conkright v.
Frommert, 559 U.S. 506, 521-22 (2010)).
Specifically, "the question is 'not which side we believe
is right, but whether the [administrator] had substantial
evidentiary grounds for a reasonable decision in its favor.'"
Matías-Correa v. Pfizer, Inc., 345 F.3d 7, 12 (1st Cir. 2003)
(quoting Brigham v. Sun Life of Can., 317 F.3d 72, 85 (1st Cir.
2003)). Evidence is deemed substantial "when it is reasonably
sufficient to support a conclusion." Cusson, 592 F.3d at 230(quoting Wright v. R.R. Donnelley & Sons Co. Grp. Benefits Plan,
402 F.3d 67, 74 (1st Cir. 2005)). Moreover, so long as substantial
-14-
evidence supports the plan administrator's decision, the decision
is not rendered unreasonable by the mere existence of evidence to
the contrary. Id.Although a plan administrator "may not arbitrarily refuse
to credit a claimant's reliable evidence, including the opinions of
a treating physician," we do not require administrators to
automatically grant "special weight" to the opinion of a claimant's
chosen provider. Black & Decker Disability Plan v. Nord, 538 U.S.
822, 834 (2003); see also Medina v. Metro. Life Ins. Co., 588 F.3d
41, 46 (1st Cir. 2009) ("A plan administrator is not obligated to
accept or even to give particular weight to the opinion of a
claimant's treating physician." (quoting Morales–Alejandro v. Med.
Card Sys., Inc., 486 F.3d 693, 700 (1st Cir. 2007))). Similarly,
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." Black & Decker, 538 U.S.
at 834. "Consequently, 'in the presence of conflicting evidence,
it is entirely appropriate for a reviewing court to uphold the
decision of the entity entitled to exercise its discretion.'"
Medina, 588 F.3d at 46 (quoting Gannon, 360 F.3d at 216).
On appeal, Ortega raises several arguments in support of
his position that the district court erred in granting judgment on
the administrative record in favor of the Appellees. Specifically,
Ortega argues that the district court erred in concluding that he
-15-
did not cooperate during the third and final FCE. He further
asserts that because Espina is not a medical doctor, the plan
administrator abused its discretion in crediting Espina's opinion
over that of Dr. Ramos. As explained below, we find that these
arguments are unpersuasive and do not require reversal.
A. Whether Ortega Did Not Cooperate with a Required Evaluation
Ortega relies heavily on his assertion that the
administrative record lacks evidence that he was uncooperative
during the third and final FCE, which was conducted on November 16,
2004. A review of the record, however, reveals significant
evidence in support of the plan administrator's decision, as
detailed in the foregoing summary of the factual background and as
further explained below.
Ortega also argues that the district court erred in
finding that because he "had successfully completed evaluations in
the past without being found uncooperative," the court could be
"confident that he understood how to try the tasks requested of
him" during his final FCE, "even if he could not complete every
one." Asserting that such a finding was based on a "selective
review" of the record, Ortega puts forth two explanations for his
lack of cooperation during the third FCE. First, he argues that he
did not complete certain evaluation tasks because he was simply
following the instructions of both Espina and his treating
physician, Dr. Ramos, to avoid actions that could cause him further
-16-
injury.7 Second, Ortega notes that there was evidence on the
record showing that he was cooperative during earlier FCEs. He
further argues that his medical condition is degenerative, and that
it is therefore only natural that he would not be able to complete
subsequent tests as well as he had completed prior evaluations.
These arguments misunderstand both the district court's
reasoning as well as the relevant standard. Immediately after
finding that Ortega knew how to complete the FCE tasks, the
district court further explained: "[i]n any event, the point is not
whether every observer would have agreed Ortega-Candelaria was
uncooperative, but whether the plan administrator had sufficient
evidence to conclude that he was uncooperative." Indeed, it is
certainly plausible that Ortega was suffering from a degenerative
condition that rendered him unable, during the third FCE, to
perform physical tasks that he had previously been able to perform
in prior FCEs. And it is further plausible that Ortega's refusal
to perform certain tasks was not because he was feigning his
injuries or exaggerating his symptoms, but was because he was
either experiencing severe pain or following his physician's orders
not to perform movements that were likely to further injure him.
7
According to Ortega, Dr. Ramos informed him that he should avoid
certain activities, including: "sitting-standing," bending,
walking, pulling, lifting, carrying, and operating foot-pedals.
Presumably, Ortega reasons that this medical advice constituted an
absolute prohibition, such that he should avoid even attempting
such activities during medical or functional evaluations.
-17-
Yet the operative standard is not whether Ortega has put
forth a plausible narrative, or whether we are more persuaded by
Ortega's account of the facts than by Appellees' version. See
Matías-Correa, 345 F.3d at 12 ("[T]he question is 'not which side
we believe is right . . . .'" (quoting Brigham, 317 F.3d at 85)).
Rather, we ask whether the plan administrator had evidence that is
"reasonably sufficient" to support its determination. See Cusson,
592 F.3d at 230 (quoting Wright, 402 F.3d at 74).
A review of the administrative record reveals that such
evidence was present here. Ortega's assertion that he was
physically unable to complete some of the tests does not vitiate
Espina's findings that Ortega failed to cooperate by putting forth
his best efforts to attempt the tasks requested during the third
FCE. While Espina did state that Ortega would not be asked to
complete any test he felt unable to perform and that he could stop
any task if pain occurred, Espina further instructed Ortega to
exert his best effort on each test absent any increased pain.
Despite this instruction, the results of Ortega's final
FCE "suggest[ed] very poor effort or voluntary sub maximal effort,
which is not necessarily related to pain, impairment or
disability." Espina's results suggested that Ortega was
"attempting to control the test results to demonstrate more pain
and disability" than he was actually experiencing. Ortega refused
to perform many of the tasks. His movements while walking did not
-18-
correspond with his pain reports. He failed eighty-six percent of
the validity criteria, which are used to determine whether a
patient is honestly using his or her best efforts to perform the
required physical tests.
Video footage further supports the conclusion that Ortega
was not cooperative; the video shows Ortega flexing his right knee
in the waiting room prior to his final FCE -- an act which he later
refused to perform during the FCE itself. Espina's evaluation
ultimately determined that Ortega's behavior and physical
performance were not consistent with his reported symptoms and
alleged disability; Espina thus concluded that Ortega was
exaggerating his symptoms.
Moreover, Espina's report was not the first indication in
the record that Ortega was exaggerating his symptoms. Dr. Seín
reported that Ortega demonstrated a "very restricted" or "sub-
minimal" effort during his first FCE. Additionally, Dr. Seín
observed that Ortega frequently shifted his weight on either leg
despite complaining of major pain symptoms with respect to only his
right leg. Ortega also demonstrated inconsistency in his
performance of a hand-grip test and refused to perform some tasks.
During the second FCE conducted by Dr. Seín, Ortega
demonstrated very inconsistent efforts and refused to perform
several tests, including some that he had previously completed in
the first FCE. On that basis, Dr. Ocasio initially recommended
-19-
denying Ortega's benefits due to this lack of cooperation.
Furthermore, following a psychiatric evaluation, Dr. Rivera
determined that Ortega gave "unreliable" information and displayed
"exaggeration of symptoms" during his examination.
With the foregoing facts in mind, we conclude that the
record contains evidence reasonably sufficient to support a
determination that Ortega was uncooperative during his evaluation.
See Cusson, 592 F.3d at 230 (deeming evidence substantial "when it
is reasonably sufficient to support a conclusion" (quoting Wright,
402 F.3d at 74)).
The Plan's terms require that Ortega cooperate during
evaluations of his disability status; without such cooperation, the
plan administrator retains the right to reduce or terminate his
benefits.8 Therefore, because the evidence on the administrative
record permits a reasonable finding that Ortega was uncooperative
during his third FCE, the Appellees' decision to terminate Ortega's
benefits cannot properly be deemed arbitrary and capricious or an
abuse of discretion. See Morales-Alejandro, 486 F.3d at 700
8
"The Plan Administrator . . . reserves the right to reduce or
terminate benefits at any time if it is determined that a
Participant no longer qualifies for benefits under the terms,
conditions, and definitions of the Plan. Without limiting the
foregoing, failure or refusal by a Participant to . . . cooperate
with any other procedures, evaluation, investigation or audit . . .
[or] cooperate with respect to the evaluation of a Participant's
Total Disability or continued Total Disability . . . shall
constitute grounds for termination of benefits under the Plan at
the sole discretion of the Plan Administrator or its authorized
representative."
-20-
(upholding the plan administrator's decision to terminate
disability benefits where evidence on the administrative record
reasonably supported such a decision); Leahy v. Raytheon Co., 315
F.3d 11, 19-20 (1st Cir. 2002) (holding that where a plan
administrator makes a decision supported by substantial evidence,
that decision cannot properly be deemed arbitrary and capricious).
B. Whether Appellees Improperly Relied on Non-Medical Evidence
Ortega further claims that the denial of his benefits was
improper because the plan administrator's decision rested on the
findings of a physical therapist rather than those of a physician.
According to Ortega, the Plan's terms require a medical evaluation
to be conducted by a physician prior to the denial of long-term
disability benefits. On that basis, in Ortega's view, Espina's
findings cannot properly support the denial of his benefits because
Espina is not a physician, and thus, could not perform a "medical"
evaluation as required by the Plan.
This argument fails to carry the day. Under the Plan's
terms, for purposes of evaluating a claim, the plan administrator
may require a claimant like Ortega to undergo an examination
conducted by a "Plan Provider."9 A "Plan Provider" means "a
Provider selected by . . . the Plan Administrator to examine or
9
Article IV of the Plan, in relevant part, states: "[i]n
evaluating the claim, the Claims Service Organization may require
additional information from the attending Provider(s) or arrange
for an examination by a Plan Provider at no cost to the
Participant."
-21-
evaluate the Participant's medical condition in order to determine
his/her Total Disability or continuing Total Disability . . . ."
A "Provider," in turn, is defined as "a person who, with respect to
any Participant: (a) is legally licensed to provide health care to
the Participant; (b) provides such care within the scope of his or
her license; and (c) is not a relative or dependent of the
Participant."
Ortega does not argue that Espina, as a physical
therapist, is not "legally licensed to provide health care" to him.
Nor does Ortega argue that conducting the FCE did not constitute
"care within the scope" of Espina's license, or that a physical
therapist cannot examine or evaluate a person's "medical condition"
in order to determine his or her disability status. Rather, Ortega
simply argues that because Espina is not a physician, the FCE did
not constitute a "medical" evaluation.
Ortega fails to point to any language in the Plan
requiring a "Provider" to be a medical doctor, or stating that an
examination cannot be conducted by a physical therapist or can only
be conducted by a physician. Instead, Ortega merely repeats his
assertions that an FCE is not a "medical" evaluation, and that only
a physician can perform a "medical" examination. We have
repeatedly held that we may disregard such bare, unsupported
assertions on appeal. See, e.g., United States v. Delgado-Marrero,
744 F.3d 167, 203 (1st Cir. 2014) (stating that the court need not
-22-
consider "conclusory allegations" or "bare assertions" in an
appellant's brief); United States v. Dellosantos, 649 F.3d 109, 126
n.18 (1st Cir. 2011) (deeming an issue waived in light of the
party's "perfunctory treatment" of a case and "lack of developed
argumentation").
Even assuming that Ortega had not waived this issue for
want of developed argument, the Plan's text does not support his
position. Had the Plan's drafters intended evaluations to be
performed solely by medical doctors, they could have selected the
specific terms "physician" or "doctor" rather than a general,
inclusive term such as "provider." Moreover, there is strong
support in Puerto Rico law for the assertion that a licensed
physical therapist is a person who "is legally licensed to provide
health care," as required by the Plan. In a Puerto Rico statute
governing the licensing of physical therapists, "physical therapy"
is defined in part as the "treatment" or "prevention" of any human
"disability, injury, illness or other condition of health," "as
well as the administration of neuromuscular tests to aid the
diagnosis or treatment of any human condition." P.R. Laws Ann.
tit. 20, § 241(1).
The requirements for a license to practice physical
therapy in Puerto Rico also include the completion of "a course of
study at a school of physical therapy recognized by the . . .
American Medical Association and/or the American Association of
-23-
Physical Therapy." Id. § 245. Finally, according to the American
Association of Physical Therapy, physical therapists are "licensed
health care professionals who can help patients reduce pain and
improve or restore mobility."10 Thus, the plan administrator had
a reasonable basis for interpreting the general term "provider" to
encompass licensed physical therapists in Puerto Rico.
Moreover, Ortega has admitted -- and the Plan's terms
explicitly state -- that the plan administrator has the right to
require one or more FCEs at any time during the claim evaluation
process. In a section titled "Exclusions from Payment of
Benefits," the Plan further provides that, "[n]otwithstanding any
other provision of this Plan," "no benefit shall be payable" if a
participant "fails or refuses to cooperate . . . with respect to
any procedure, evaluation, investigation or audit in connection
with this Plan . . . whether performed by the Plan Administrator
. . . or any other delegate of the Plan Administrator." This
exclusionary provision does not require an "evaluation" or
"investigation" to be a "medical" examination or evaluation. Nor
does the provision require that the person conducting an evaluation
be a "provider" as defined in the Plan; instead, the evaluation may
be conducted by "any other delegate" of the plan administrator.
10
Am. Physical Therapy Ass'n, Who Are Physical Therapists?,
http://www.apta.org/AboutPTs/ (last updated May 23, 2013).
-24-
Ortega has also conceded that the Plan grants the plan
administrator the discretionary authority to construe and interpret
the Plan's terms. On that basis, Ortega agrees, as he must, that
the applicable standard of review is the deferential arbitrary-and-
capricious or abuse-of-discretion standard. See Cusson, 592 F.3d
at 224; Gross, 734 F.3d at 11. Accordingly, we cannot say that it
was arbitrary, capricious, or an abuse of discretion for the plan
administrator to interpret the Plan's language as permitting the
termination of benefits based on FCE determinations that Ortega was
exaggerating his symptoms and was not cooperating with his
evaluation. Therefore, Ortega's arguments on this issue are
unavailing.
C. The Effect of Appellees' Failure to Adopt Dr. Ramos's Opinion
Lastly, Ortega relies on the opinion of his treating
physician, Dr. Ramos, to establish that he was "totally disabled,"
in order to discredit Espina's findings that Ortega was
uncooperative during the third FCE. Ortega asserts that it was
error for the plan administrator to credit Espina's assessment over
that of Dr. Ramos.
Ortega is correct that a plan administrator "may not
arbitrarily refuse to credit" the opinion of a claimant's treating
physician. See Black & Decker, 538 U.S. at 834 (emphasis added).
Here, however, Ortega has failed to establish that there was any
such arbitrary rejection of Dr. Ramos's opinion or, indeed, of any
-25-
other reliable evidence supporting Ortega's position. And
Appellees were under no mandate to grant "special weight" to the
opinions of Ortega's attending physician. See id.Essentially, Ortega asks us to hold that the opinion of
Dr. Ramos, as Ortega's attending physician, necessarily controls
over contradictory evidence in the record. Such a position,
however, flies in the face of our precedent. See Richards v.
Hewlett-Packard Corp., 592 F.3d 232, 240 (1st Cir. 2010) ("[T]he
opinion of the claimant's treating physician, which was considered,
is not entitled to special deference.") (quoting Orndorf v. Paul
Revere Life Ins. Co., 404 F.3d 510, 526 (1st Cir. 2005)); Morales-
Alejandro, 486 F.3d at 700 ("[A] plan administrator is not
obligated to accept or even to give particular weight to the
opinion of a claimant's treating physician.").
Ortega cites several cases from other jurisdictions in
support of his argument that an attending physician's medical
evaluation should be given more weight than an FCE performed by a
physical therapist or another non-physician. Ortega's reliance on
these cases is misplaced. The first district court case relied
upon by Ortega was later remanded by the Eleventh Circuit and then
subsequently vacated upon the parties' settlement. See Ridge v.
Hartford Life & Accident Ins. Co., 339 F. Supp. 2d 1323 (M.D. Fla.
2004), vacated, No. 8:03CV1871T26EAJ, 2005 WL 889964 (M.D. Fla.
Apr. 7, 2005). Even if Ridge were not a vacated district court
-26-
case from another circuit, the factual predicate for its holding is
inapposite. In Ridge, the court found that "[n]othing in the Plan
defines an FCE, and nothing in the Plan permits [the insurer] to
require an FCE." 339 F. Supp. 2d at 1336. Here, in contrast, the
Plan explicitly provides that "[o]ne or more . . . Functional
Capacity Examination(s) (FCE) may be required at any time during
the claim evaluation process."
Ortega next relies upon Lamanna v. Special Agents Mut.
Benefits Ass'n, 546 F. Supp. 2d 261 (W.D. Pa. 2008), and Stup v.
UNUM Life Ins. Co. of Am., 390 F.3d 301 (4th Cir. 2004), abrogated
by Williams v. Metro. Life Ins. Co., 609 F.3d 622 (4th Cir. 2010).
Ortega emphasizes the Lamanna court's statement that "tests of
strength such as a functional capacity evaluation ('FCE') can
neither prove nor disprove claims of disabling pain." See Lamanna,
546 F. Supp. 2d at 296. However, Lamanna does not advance Ortega's
cause for at least three reasons.
First, the court concluded the sentence highlighted by
Ortega as follows: FCEs do not "necessarily present a true picture
in cases involving fibromyalgia where the symptoms are known to wax
and wane, thereby causing test results potentially to be
unrealistic measures of a person's ability to work on a regular,
long-term basis." Id. The record here, however, does not
establish that Ortega suffers from fibromyalgia. Second, the
Lamanna court also explained that "[w]hile the amount of fatigue or
-27-
pain an individual experiences may be entirely subjective, the
extent to which those conditions limit her functional capabilities
can be objectively measured." Id. at 296. Here, the three FCEs
sought to objectively measure the limitations of Ortega's
functional capabilities, and all three FCEs involved at least some
indication that Ortega was exaggerating his symptoms or was not
exerting his best efforts.
Third, the Lamanna court found that there were "numerous
procedural inconsistencies which demonstrate reliance on medical
reviews based on incomplete records, failure to adequately analyze
the reports of Plaintiff's treating physicians, and unrealistic
demands for objective evidence of fibromyalgia and chronic fatigue
syndrome." Id. at 288. The court further found that the
administrator's decision was not based on substantial evidence
because "there were significant omissions, mis-interpretations, and
unreasonable expectations in the reports of the medical consultants
upon which [the administrator] relied in reaching its conclusion."
Id. at 289. By means of contrast, in the record before us, we have
identified neither "numerous procedural inconsistencies" nor
"significant omissions, mis-interpretations, and unreasonable
expectations" in the reports upon which the plan administrator
relied. Cf. id. at 288-89.
Ortega cites Stup for the proposition that because the
FCE in that case "lasted only two and a half hours, . . . the FCE
-28-
test results do not necessarily indicate Stup's ability to perform
sedentary work for an eight . . . hour workday, five days a week."
Stup, 390 F.3d at 309. Unlike the instant case, however, the
claimant in Stup had provided the insurer with years of
"substantial medical evidence supporting her diagnosis," id. at
311, and the only evidence to the contrary was "[a]n equivocal
opinion" that was "based on ambiguous test results." Id. at 310.
The physical therapist in Stup "twice expressly
recognized the ambiguity of the FCE results and hedged her negative
interpretation of them." Id. The therapist in that case concluded
her report by warning "that it would not be 'prudent' to use the
FCE results to determine Stup's ability to perform 'specific job
duties.'" Id. Here, on the other hand, Espina unequivocally
concluded that Ortega was exaggerating his symptoms and
disabilities. Espina reported that Ortega failed eighteen out of
twenty-one validity criteria, indicating a significant lack of
cooperation with the evaluation -- a determination that constitutes
grounds for termination of benefits under the Plan. Thus, the
reasoning embraced by Stup does not control the result here.
Moreover, all three cases relied upon by Ortega on this
issue presumed that a heightened standard of review applies if the
defendant has a structural conflict of interest. See id. at 307,
311 (applying a less-deferential standard of review because the
defendant "acted under a conflict of interest" -- its dual role as
-29-
both payer of benefits and arbiter of claims meant that "its
decision to deny benefits impacted its own financial interests");
Lamanna, 546 F. Supp. 2d at 286 (applying "a moderately heightened
level of scrutiny" because of the particular conflict of interest
caused by the relationship between the claims administrator and the
insurer); Ridge, 339 F. Supp. 2d at 1334 ("Because Hartford, as
claims administrator, is also the insurance company responsible for
paying the claims, the heightened arbitrary and capricious standard
[would be] applicable . . . . [if] Hartford operated under a
conflict of interest.").
However, the Supreme Court has since clarified that the
presence of a conflict of interest does not alter the standard of
review, but rather is "but one factor among many that a reviewing
judge must take into account." Metro. Life Ins. Co. v. Glenn, 554
U.S. 105, 116 (2008). Thus, the standard of review here remains
the deferential abuse-of-discretion standard. See id.; Cusson, 592
F.3d at 224. While a conflict of interest "can, under certain
circumstances, be accorded extra weight in the court's analysis,"
Cusson, 592 F.3d at 224, Ortega does not argue that such
circumstances are present here.
Contrary to Ortega's arguments, we have previously held
that an administrator's decision to terminate disability benefits
was not arbitrary and capricious even where that decision was
supported in part by an FCE conducted by a physical therapist and
-30-
was directly contradicted by the claimant's two treating
physicians. See Gannon, 360 F.3d at 213-16. The administrator's
decision in Gannon was supported by: an FCE conducted by a physical
therapist; the opinion of an "independent medical consultant who
reviewed [the claimant's] file"; a transferable skills analysis
prepared by a vocational consultant; a surveillance report; and the
denial of Gannon's claim for social security disability benefits.
Id. at 213-15.
As in the case at hand, the FCE in Gannon "indicated that
[the claimant] did not put forth her maximum effort during the
tests . . . and that her performance was inconsistent in various
ways." Id. at 213. The FCE provided evidence that the claimant
was exaggerating her symptoms and that she was physically capable
of performing restricted work activities. Id. Given the findings
of the FCE and conclusions of the physical therapist, we found it
reasonable for the plan administrator to rely upon the FCE as
evidence in support of its determination that Gannon was not
"disabled" under the Plan. Id.Similarly, the Tenth Circuit has held that the results of
two FCEs -- both administered by physical therapists -- provided
substantial evidence upon which the plan administrator could have
based its decision to deny benefits. Buckardt v. Albertson's,
Inc., 221 F. App'x 730, 735-37 (10th Cir. 2007). Much like Ortega,
the plaintiff in Buckardt argued that the "FCEs were not medical
-31-
evaluations" and that an FCE administered by a physical therapist
cannot provide substantial evidence for a decision to terminate
benefits. Id. at 735-36. The Tenth Circuit disagreed, reasoning
that such a position is contrary to the prevailing precedent in
several circuits. Id. at 736 (citing Gannon, 360 F.3d at 213, and
Jackson v. Metro. Life Ins. Co., 303 F.3d 884, 888 (8th Cir.
2002)).
The Eleventh Circuit has also addressed a similar
argument from a claimant maintaining that an FCE from a physical
therapist should not have been given more weight than the opinion
of the claimant's treating physician. See Townsend v. Delta
Family-Care Disability & Survivorship Plan, 295 F. App'x 971, 977
(11th Cir. 2008). In rejecting this argument, the Eleventh Circuit
reasoned that "FCEs are routinely conducted by physical therapists"
and "plan administrators routinely rely on FCEs." See id.; see
also Duncan v. Fleetwood Motor Homes of Ind., Inc., 518 F.3d 486,
489 (7th Cir. 2008); Baker v. Barnhardt, 457 F.3d 882, 885-86 (8th
Cir. 2006). Thus, we have not found compelling support for
Ortega's argument that a plan administrator cannot rely on the
findings of an FCE conducted by a physical therapist.
Even if we were inclined to accept Ortega's theory that
a medical doctor's opinion must be given more weight than the
opinion of a non-physician, the record here also contains the
opinions of medical doctors that support the plan administrator's
-32-
decision. As previously summarized, Dr. Seín found -- in two
successive FCEs -- that Ortega demonstrated sub-par effort as well
as inconsistencies between his reported pain and his physical
movements. During each FCE, Ortega also refused to perform some
tests. Reviewing the results of the second FCE conducted by
Dr. Seín, Dr. Ocasio initially recommended denying Ortega's
benefits due to his lack of cooperation. Additionally, Dr. Rivera
concluded that Ortega provided "unreliable" information and
exaggerated his psychiatric symptoms. Therefore, the record shows
that the opinions of several doctors provide further support for
the plan administrator's decision.
We have previously held that the mere existence of
contrary medical evidence does not render arbitrary and capricious
a plan administrator's decision to credit one opinion over another.
See Gannon, 360 F.3d at 213. "Indeed, when the medical evidence is
sharply conflicted, the deference due to the plan administrator's
determination may be especially great." Leahy, 315 F.3d at 19.
The plan administrator here reviewed and considered
Dr. Ramos's findings, but it ultimately concluded that other
evidence in the administrative record -- including Espina's report
that Ortega was uncooperative and exaggerating his symptoms -- was
more persuasive. On that basis, the administrator exercised its
discretion to determine that Ortega was no longer eligible to
receive plan benefits for his alleged continuing disability. See
-33-
Medina, 588 F.3d at 46 ("[I]n the presence of conflicting evidence,
it is entirely appropriate for a reviewing court to uphold the
decision of the entity entitled to exercise its discretion."
(quoting Gannon, 360 F.3d at 216)). Such a conclusion, supported
by substantial evidence, is neither arbitrary, nor capricious, nor
an abuse of discretion. See Leahy, 315 F.3d at 18-19 (finding that
where a plan administrator's determination that the insured was not
fully disabled rests on substantial evidence, it cannot be said
that such a decision is arbitrary and capricious).
III. Conclusion
Given the contents of the administrative record, the plan
administrator's finding that Ortega was uncooperative during his
final FCE -- and thus ineligible for continuing benefits -- was
reasonable and supported by substantial evidence. The
administrator's decision to terminate Ortega's long-term disability
benefits was, therefore, neither arbitrary nor capricious. In so
doing, the administrator also did not abuse its discretion to
construe and interpret the Plan's terms and determine whether there
existed grounds for termination of Ortega's benefits. For the
foregoing reasons, we affirm the judgment of the district court.
AFFIRMED.
-34-