United States Court of Appeals
For the First Circuit
No. 03-1032
NANCY MATIAS-CORREA,
Plaintiff, Appellant,
v.
PFIZER, INC.; MEDICAL CARD SYSTEMS, INC.,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Héctor M. Laffitte, U.S. District Judge]
Before
Lynch, Lipez, and Howard, Circuit Judges.
Raymond L. Sanchez Maceira for appellant.
Carl Schuster, with whom Lourdes C. Hernández-Venegas and
Schuster, Usera & Agulió LLP, were on brief for appellees.
September 25, 2003
HOWARD, Circuit Judge. Plaintiff-appellant Nancy Matías-
Correa appeals the district court's entry of summary judgment in
favor of defendants-appellees Pfizer, Inc. ("Pfizer"), and Medical
Card System, Inc. ("MCS"), in a suit in which Matías alleged that
the termination of her disability benefits violated the Employee
Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§
1001-1461. We affirm.
I. Factual and Procedural Background
Matías worked as a machine operator for Pfizer (formerly
Warner-Lambert) in a Puerto Rico facility, starting as a temporary
employee in 1986 and working on a permanent basis from September
1988 until November 1995. While employed by Pfizer, Matías
participated in Pfizer's Long Term Disability Benefits Plan, which
provides disability benefits for participants who are "totally
disabled." A participant is considered totally disabled under the
terms of the plan if, during the first two years of disability, she
is "unable to perform the basic duties of [her] occupation, and
[is] not involved in any other gainful occupation." After
receiving plan benefits for two years, however, a participant will
only be considered totally disabled if she is "unable to work in an
occupation or job for which [she is] qualified or may be qualified
based on [her] academic background, training or experience." MCS
acted as claims administrator for the plan.
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In April 1996, Matías applied for and was granted
disability benefits under the plan, based on her condition of low
back pain syndrome, radiculopathy, and depression. At the time,
her condition satisfied the plan's first definition of "total
disability."
After two years passed, however, Matías could only
continue to receive benefits if her physical condition satisfied
the second definition of total disability.1 Under the terms of the
plan, a participant receiving benefits "may be required to undergo
a medical examination . . . and/or to submit evidence of continued
Total Disability satisfactory to [MCS] . . . to determine [her]
continued entitlement to disability benefits or ability to resume
active employment." Further, such a participant would periodically
"be required to submit evidence to [MCS] of [her] continued total
disability," and refusal to submit such evidence would result in
the discontinuation of benefits.
On April 6, 2001, MCS requested that Matías submit copies
of all medical records and progress notes of her treating doctors.
Matías complied, submitting records from a variety of medical
professionals, including her rheumatologist, neurologist, and
psychiatrist. MCS referred Matías's file to Dr. José Ocasio, an
independent occupational medical consultant, for an independent
1
The plan restricted benefits based on mental disability to a
maximum of two years.
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medical evaluation. On May 14, 2001, Dr. Ocasio made a preliminary
finding that Matías's records did not indicate total disability.
He noted that Matías did not appear to be following a regular
treatment schedule with her physicians, and recommended a
Functional Capacity Evaluation ("FCE").
Matías's FCE showed that she was able to work at a
“sedentary physical demand level” during an eight-hour day. The
tests suggested symptom exaggeration by Matías and "very poor
effort or voluntary submaximal effort which is not necessarily
related to pain, impairment or disability." Based on these results
and his prior findings, Dr. Ocasio recommended the termination of
Matías's disability benefits on the ground that she was not totally
disabled. MCS terminated Matías’s disability benefits, effective
June 15, 2001.
On August 3, 2001, Matías filed a first-level appeal of
her benefits termination with MCS. As part of this appeal, she
submitted additional medical documents, including three undated
doctors’ assessments of her physical capabilities during an eight-
hour workday. These “Residual Functional Capacity Assessments”
(“RFC Assessments”) varied in their conclusions as to the amount of
activity Matías could tolerate. For example, one doctor estimated
that Matías could sit for less than one hour and stand for less
than one hour, while another estimated that she could sit for two
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to four hours and stand for one to two hours. All found that
Matías needed rest periods during the day.
MCS referred Matías’s full medical file, including the
new documents submitted on appeal, to Dr. Ocasio for evaluation,
and on August 13, 2001, Dr. Ocasio once again recommended the
termination of Matías’s benefits. He found that the additional
materials confirmed that Matías was not totally disabled,
concluding in particular that all three RFC Assessments indicated
that Matías could work for short periods of time, with rest. Two
days later, MCS affirmed its termination of Matías’s benefits,
notifying her that she did not meet the definition of "totally
disabled" under the plan. MCS concluded that although Matías
suffered from several physical conditions that required treatment,
she was able to work. MCS also informed Matías of her right to
appeal the decision by submitting any additional evidence she
wished to have considered.
Matías requested a second-level appeal, and on October
12, 2001, she submitted updated progress notes from her
psychiatrist, Dr. José Bisbal, and the results of an MRI performed
on her right knee.2 She also resubmitted a number of the medical
documents she had already provided as part of her initial review
and first appeal. Dr. Ocasio again reviewed Matías’s medical
2
The MRI revealed some abnormalities in Matías’s knee,
including tears and degeneration.
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evidence, and concluded that she was not "totally disabled." On
October 30, 2001, MCS issued its final denial of Matías’s appeal,
and affirmed the termination of her benefits.
In November 2001, Matías filed suit against Pfizer and
MCS in the United States District Court for the District of Puerto
Rico, claiming a violation of ERISA based on the termination of her
benefits. Matías claimed that she suffered from debilitating
conditions and that MCS’s decision to terminate her benefits was
arbitrary and capricious. In September 2002, Pfizer and MCS moved
for summary judgment on the ground that the benefits determination
was supported by substantial evidence in the record. In November
2002, the district court entered judgment in favor of defendants.
The court found that (1) the standard of review was arbitrary and
capricious because the plan granted the necessary discretionary
authority to MCS; and (2) MCS had not acted arbitrarily or
capriciously in light of substantial record evidence supporting
MCS’s termination of benefits. This appeal followed.
II. Analysis
A. The ERISA Standard of Review
Matías alleges that the district court erred in reviewing
MCS’s benefits determination under an “arbitrary and capricious”
standard. Such a standard of review is appropriate where the
language of the benefits plan reflects a “clear grant of
discretionary authority to determine eligibility for benefits.”
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Leahy v. Raytheon Co., 315 F.3d 11, 15 (1st Cir. 2002) (citing
Terry v. Bayer Corp., 145 F.3d 28, 37 (1st Cir. 1998)); see
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
The plan states that MCS “shall administer claims under
the Plan,” and
[S]hall have the power and the duty, including
discretionary authority, to take all actions and to make
all decisions necessary or proper to carry out the
provisions of the Plan, including, but not limited to,
the following:
* * *
To interpret the Plan to determine whether a claimant is
eligible for benefits, to decide the amount, form, and
timing of benefits, and to resolve ambiguities,
inconsistencies, omissions and any other claim-related
matters under the Plan which is [sic] raised by a
claimant or identified by the Investment Committee, its
interpretation and resolution to be final, conclusive and
binding on all parties affected thereby
App. at 69-70 (emphasis added).
Despite this language, Matías alleges that the plan did
not grant final discretionary authority to MCS because Pfizer has
retained the authority to reverse MCS’s decisions concerning the
plan. As support, Matías points to language in the plan granting
an internal committee at Pfizer (the “Investment Committee”)
authority to administer the plan.3 The district court rejected
3
Matías refers to a provision stating:
The Investment Committee shall administer the Plan and shall
have the power and the duty, including discretionary
authority, to take all actions and to make all decisions
necessary or proper to carry out the Plan, including, but not
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this argument, noting the unequivocal authority of MCS to
administer claims under the plan, a power not assigned to the
Investment Committee.
While the Investment Committee appears to hold some
administrative authority under the terms of the plan, MCS is the
entity designated to administer claims under the plan, and to
interpret the plan to determine a claimant’s eligibility for
benefits. MCS’s eligibility determinations are “final, conclusive
and binding on all parties affected thereby.” Matías offers no
basis to conclude that MCS lacked the discretionary authority to
make the necessary judgment calls concerning her eligibility for
limited to, the following:
(a) To require any person to furnish such information as it
may request for the purpose of the proper administration
of the Plan as a condition to receiving any benefit under
the Plan;
(b) To make and enforce such rules and regulations and
prescribe the use of such forms as it shall deem
necessary or desirable for the efficient administration
of the Plan;
(c) To interpret the Plan, and to resolve ambiguities,
inconsistencies and omissions, its interpretation and
resolution to be finally conclusive and binding on all
parties affected thereby;
(d) To decide on questions concerning the Plan and the
eligibility of any Employee to participate in the Plan in
accordance with the provisions of the Plan;
(e) To compute the amount of benefits which shall be payable
to any person in accordance with the provisions of the
Plan . . . .
App. at 71.
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benefits. The district court properly applied the arbitrary and
capricious standard of review.
B. The Benefits Determination
We review de novo the district court’s entry of summary
judgment in favor of the defendants. See Twomey v. Delta Airlines
Pension Plan, 328 F.3d 27, 31 (1st Cir. 2003). Where the
underlying decision by a plan administrator is subject to the
arbitrary and capricious standard of review, our review involves an
inquiry into “whether the aggregate evidence, viewed in the light
most favorable to the non-moving party, could support a rational
determination that the plan administrator acted arbitrarily in
denying the claim for benefits.” Id. (quoting Leahy, 315 F.3d at
18). The touchstone is whether MCS's benefits determination was
reasonable. See Liston v. UNUM Corp. Officer Severance Plan, 330
F.3d 19, 24 (1st Cir. 2003).
Matías contends that MCS’s conclusion that she was not
totally disabled “is at odds with the generally recognized
requirement for sedentary jobs,” including the requirements set
forth by the Social Security Administration. As the district
court noted, however, Matías was required to satisfy the plan’s
definition of total disability (i.e. that she was completely
unable to work in an occupation for which she was, or might be,
qualified based on her background). Cf. Pari-Fasano v. ITT
Hartford Life & Accident Ins. Co., 230 F.3d 415, 420 (1st Cir.
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2000) (“[A]lthough a related Social Security benefits decision
might be relevant to an insurer’s eligibility determination, it
should not be given controlling weight except perhaps in the rare
case in which the statutory criteria are identical to the criteria
set forth in the insurance plan.”).
Matías also alleges that MCS relied too heavily on the
results of its own investigation, and should have given more
weight to her doctors’ diagnoses, including those that “flatly
contradicted the FCE.” But under the applicable standard of
review, the question is “not which side we believe is right, but
whether the insurer had substantial evidentiary grounds for a
reasonable decision in its favor." Brigham v. Sun Life of Canada,
317 F.3d 72, 85 (1st Cir. 2003)(alterations omitted)(quoting Doyle
v. Paul Revere Life Ins. Co., 144 F.3d 181, 184 (1st Cir. 1998));
see Lopes v. Metropolitan Life Ins. Co., 332 F.3d 1, 6 (1st Cir.
2003); see also Black & Decker Disability Plan v. Nord, --- U.S.
---, 123 S. Ct. 1965, 1971 (2003) (“Plan administrators . . . may
not arbitrarily refuse to credit a claimant’s reliable evidence,
including the opinions of a treating physician. But . . . courts
have no warrant to require administrators automatically to accord
special weight to the opinions of a claimant’s physician.”).
MCS considered medical evidence that supported its
conclusion that, while Matías was in need of medical treatment,
she was not totally disabled within the meaning of the plan.
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Matías’s FCE generated evidence that she was capable of sedentary
physical work. That exam also showed signs of symptom
exaggeration. Matías also submitted evidence, including three RFC
Assessments, from which an independent medical expert concluded
that she could work for limited periods of time, with rest. In
light of the record evidence taken as a whole, we find that MCS’s
termination of Matías’s benefits was within its discretion.
Affirmed.
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