Candelaria v. Johnson & Johnson, 1st Cir. (2014)

7/26/2019 Candelaria v. Johnson & Johnson, 1st Cir. (2014)

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United States Court of AppealsFor the First Circuit

No. 13- 1564

ROLANDO ORTEGA- CANDELARI A,

Pl ai nt i f f , Appel l ant ,

v.

J OHNSON & J OHNSON; MEDI CAL CARD SYSTEM, I NC. ,

Def endant s, Appel l ees.

APPEAL FROM THE UNI TED STATES DI STRI CT COURTFOR THE DI STRI CT OF PUERTO RI CO

[ Hon. J os Ant oni o Fust , U. S. Di st r i ct J udge]

Bef or e

Tor r uel l a, Bal dock, * and Kayat t a,

Ci r cui t J udges.

Pedr o J . Landr au- Lpez, f or appel l ant .Lour des C. Her nndez- Venegas, wi t h whom El i zabet h Pr ez-

Ll er as, Shi ar a L. Di l on- Fer nndez and Schust er Agui l LLP, wer e onbr i ef f or appel l ees.

J une 16, 2014

* Of t he Tent h Ci r cui t , si t t i ng by desi gnat i on.


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TORRUELLA, Circuit Judge. Pl ai nt i f f - Appel l ant Rol ando

Or t ega- Candel ar i a ( "Or t ega") appeal s t he di st r i ct cour t ' s di smi ssal

of hi s cl ai ms under t he Empl oyee Ret i r ement I ncome Secur i t y Act

( "ERI SA") , 29 U. S. C. 1001- 1461. Bef or e t he di st r i ct cour t ,

Or t ega sought j udi ci al r evi ew of t he deci si on t o t ermi nat e payment

of di sabi l i t y benef i t s t o hi m under J ohnson & J ohnson' s Long- Ter m

Di sabi l i t y Pl an ( t he "Pl an") . Or t ega r equest ed a j udgment

r est or i ng hi s t er mi nat ed benef i t s and order i ng payment of past

benef i t s. The di st r i ct cour t di smi ssed Or t ega' s cl ai ms wi t h

pr ej udi ce.

On appeal , Or t ega ar gues t hat J ohnson & J ohnson and

Medi cal Car d Syst em, I nc. ( "MCS") ( col l ect i vel y, t he "Appel l ees" )

ar bi t r ar i l y and capr i ci ousl y t er mi nat ed hi s di sabi l i t y benef i t s.

Or t ega cont ends t hat t he Appel l ees er r oneousl y credi t ed an

exami nat i on by a physi cal t her api st over t he opi ni on of hi s

t r eat i ng physi ci an. Gi ven t he subst ant i al r ecor d evi dence

suppor t i ng t he Appel l ees' det er mi nat i on, we f i nd t hat t he deci si on

t o t er mi nat e Or t ega' s benef i t s di d not const i t ut e an abuse of

di scr et i on and was nei t her arbi t r ar y nor capr i ci ous. We af f i r m.

I. Background

A. The Plan

J ohnson & J ohnson sponsor s t he Pl an t o provi de l ong- t er m

di sabi l i t y benef i t s f or i t s empl oyees and t he empl oyees of i t s

af f i l i at ed compani es. Or t ega r ecei ved cover age under t he Pl an

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whi l e wor ki ng i n Puer t o Ri co as an el ect r i ci an f or Or t ho Bi ol ogi cs

LLC, a subsi di ar y of J ohnson & J ohnson.

I n or der t o be el i gi bl e f or pl an benef i t s, a par t i ci pant

must be consi der ed "t ot al l y di sabl ed. " Dur i ng t he f i r st t wel ve

mont hs of an i nj ur y or si ckness, a pl an par t i ci pant must be unabl e

t o per f or m t he essent i al f unct i ons of hi s or her "r egul ar j ob" i n

or der t o qual i f y as "t ot al l y di sabl ed. " I f t he i nj ur y or si ckness

l ast s l onger t han t wel ve mont hs, t he par t i ci pant must r emai n

compl et el y unabl e "t o do any j ob" - - "wi t h or wi t hout r easonabl e

accommodat i on, " and " f or whi ch t he Par t i ci pant i s ( or may

r easonabl y become) qual i f i ed by t r ai ni ng, educat i on, or exper i ence"

- - i n or der t o cont i nue t o be cl assi f i ed as "t ot al l y di sabl ed. "

Pur suant t o t he Pl an, t he pl an admi ni st r at or mai nt ai ns

"t he r i ght t o conduct eval uat i ons of a Par t i ci pant ' s medi cal st at us

and el i gi bi l i t y f or benef i t s" at any t i me whi l e a cl ai m i s pendi ng

or t he par t i ci pant i s r ecei vi ng benef i t s. 1 The Pl an f ur t her gr ant s

t he pl an admi ni st r at or t he sol e di scr et i on " t o const r ue and

i nt er pr et " t he Pl an' s t er ms and t he sol e di scr et i on t o det er mi ne

1 As def i ned i n t he Pl an, and as used her ei n, t he t er m "pl anadmi ni st r ator" encompasses bot h t he J ohnson & J ohnson Pensi onCommi t t ee ( "Pensi on Commi t t ee") and MCS, t he cl ai ms servi ces

or gani zat i on r et ai ned by J ohnson & J ohnson t o pr ovi deadmi ni st r at i ve ser vi ces rel at ed t o t he Pl an. "I n t he event of adeni al or l i mi t at i on of benef i t s, " a par t i ci pant may appeal t o MCS.I f MCS uphol ds t he or i gi nal deni al of benef i t s, t he par t i ci pant mayappeal a second t i me t o t he Pensi on Commi t t ee. A par t i ci pant maycommence a l awsui t onl y af t er a f i nal deci si on has been r endered ont hi s second appeal .

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whet her t her e exi st gr ounds f or t er mi nat i on of a par t i ci pant ' s

benef i t s. 2 Under t he Pl an, such gr ounds i ncl ude a cl ai mant ' s

f ai l ur e to cooper at e wi t h r espect t o any pr ocedur e or eval uat i on i n

connect i on wi t h t he Pl an. 3

A par t i ci pant maki ng a cl ai m f or benef i t s under t he Pl an

must pr ovi de "al l i nf or mat i on necessary to eval uat e hi s or her

medi cal condi t i on and f unct i onal capaci t y. " At the pl an

admi ni st r at or ' s di scr et i on, " t he eval uat i on may i ncl ude medi cal

exami nat i on( s) by a Pl an Pr ovi der . " Fur t her , " [ o] ne or mor e

I ndependent Medi cal Exami nat i on( s) ( I ME) and Funct i onal Capaci t y

2 I n r el evant par t , Ar t i cl e VI I of t he Pl an st at es that t he pl anadmi ni st r at or "has t he sol e aut hor i t y t o . . . [ e] xer ci se i t sdi scret i on t o det er mi ne el i gi bi l i t y f or benef i t s, t o const r ue andi nt er pr et t he pr ovi si ons of t he Pl an and t o r ender concl usi ve andbi ndi ng deci si ons and det er mi nat i ons based t her eon. "

3

I n t he sect i on t i t l ed "Eval uat i on of Par t i ci pant ' s Medi calSt at us, " t he Pl an st at es t hat a par t i ci pant maki ng a cl ai m i sr equi r ed t o "cooper at e . . . i n t he eval uat i on of t he Par t i ci pant ' smedi cal st at us. " "Fai l ur e or r ef usal by t he Par t i ci pant t ocooper at e i n t he medi cal eval uat i on . . . shal l const i t ut e gr oundsf or t er mi nat i ng benef i t s under t he Pl an. "

I n a sect i on t i t l ed "Excl usi ons f r om Payment of Benef i t s, " thePl an f ur t her st at es, i n r el evant par t , t hat :

Not wi t hst andi ng any ot her pr ovi si on of t hi s Pl an, i n noevent shal l a Par t i ci pant be consi der ed Tot al l y Di sabl ed

or r emai n Tot al l y Di sabl ed, and no benef i t shal l bepayabl e under t hi s Pl an . . . on or af t er t he dat e aPar t i ci pant . . . f ai l s or r ef uses t o cooper at e wi t hr espect t o t he eval uat i on of hi s/ her Tot al Di sabi l i t y orcont i nui ng Tot al Di sabi l i t y or wi t h r espect t o anypr ocedur e, eval uat i on, i nvest i gat i on or audi t i nconnect i on wi t h t hi s Pl an . . . .

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Exami nat i on( s) ( FCE) may be requi r ed at any t i me dur i ng t he cl ai m

eval uat i on pr ocess. "

B. Ortega's Claim Under the Plan

As an el ect r i ci an f or Or t ho Bi ol ogi cs LLC, Or t ega hel d a

"most l y act i ve" j ob t hat r equi r ed "bendi ng, wal ki ng, cl i mbi ng,

[ and] wor ki ng [ i n a] st andi ng posi t i on f or l ong per i od[ s] of t i me, "

and whi ch r equi r ed hi m t o "pul l , push, l i f t / car r y and squat " on a

"r out i ne basi s. "

Or t ega al l eges t hat si nce 2002, he has been unabl e t o

wor k due t o const ant pai n caused by ver t ebr al her ni at i ons,

degener at i ve scol i osi s, ost eoar t hr i t i s, and r adi cul opat hi es. He

al so cl ai ms t o suf f er f r omanxi et y, pani c di sor der , and depr essi on.

As a resul t of t hese condi t i ons, Or t ega went on non- occupat i onal

di sabi l i t y l eave, and he began r ecei vi ng shor t - t er m di sabi l i t y

benef i t s on Oct ober 28, 2002. Subsequent l y, on J une 3, 2003,

Or t ega submi t t ed hi s f i r st cl ai mf or l ong- t er mdi sabi l i t y benef i t s,

i n whi ch he asser t ed t hat he was unabl e to bend or wal k,

exper i enced consi st ent pai n i n hi s l egs and back, and suf f er ed f r om

anxi et y, pani c at t acks, and depr essi on.

Shor t l y t her eaf t er , MCS r ecei ved t wo "At t endi ng Physi ci an

St at ement s" i n suppor t of Or t ega' s cl ai m. The f i r st of t hese

st atement s addr essed Or t ega' s ment al and emot i onal condi t i on,

concl udi ng t hat Or t ega suf f er ed f r om pani c di sor der as wel l as

"maj or depr essi on. " The second st at ement , r egar di ng Or t ega' s

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physi cal ai l ment s, speci f i ed t hat he suf f er ed f r omradi cul opat hi es,

her ni at i on of l umbosacral di scs, degener at i ve scol i osi s, and

osteoar t hr i t i s .

Or t ega' s cl ai mf or l ong- t er mdi sabi l i t y benef i t s f or hi s

physi cal condi t i on was appr oved on J ul y 23, 2003, but Or t ega was

not i f i ed t hat such benef i t s woul d appl y r et r oact i vel y begi nni ng

f r omJ une 24, 2003. Or t ega' s cl ai mf or benef i t s due t o hi s ment al -

heal t h sympt oms, however , was deni ed. I n i t s subsequent

conf i r mat i on of t he appr oval of Or t ega' s physi cal cl ai m, MCS

advi sed Or t ega that he was r equi r ed t o undergo regul ar t r eat ment

wi t h a speci al i st and t hat hi s case woul d be r eeval uat ed

per i odi cal l y by MCS' s Medi cal Commi t t ee t o deter mi ne hi s cont i nued

el i gi bi l i t y f or l ong- t erm di sabi l i t y benef i t s .

On Oct ober 20, 2003, MCS request ed t hat Or t ega pr ovi de a

copy of t he medi cal r ecor ds hel d by hi s at t endi ng physi ci ans at t he

t i me i n or der t o det er mi ne hi s cont i nued el i gi bi l i t y f or l ong- t er m

di sabi l i t y benef i t s. Ther eaf t er , on Oct ober 30, 2003, Or t ega

par t i ci pat ed i n a f unct i onal capaci t y eval uat i on ( "FCE") conduct ed

by Raf ael E. Se n, M. D. ( "Dr . Se n") , a physi at r i st , or

r ehabi l i t at i on physi ci an.

Dr . Se n r epor t ed t hat Or t ega: "demonst r at ed a ver y

r est r i ct ed" - - or "submi ni mal " - - "ef f or t dur i ng t he wei ght ed and

non- wei ght ed act i vi t i es, wi t h a mor e ment al i nvol vement t hat

aggr avat es hi s physi cal condi t i on" ; f r equent l y shi f t ed wei ght on

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ei t her l eg despi t e hi s maj or pai n sympt oms bei ng r el at ed t o hi s

r i ght l eg onl y; "demonst r at ed i nconsi st ency" on a hand- gr i p t est ;

and r ef used t o per f or m some act i vi t i es due t o f ear of bei ng

i nj ur ed. On t hat basi s, Dr . Se n r ecommended an i ndependent

psychi at r i st eval uat i on. He concl uded t hat Or t ega had t he physi cal

capaci t y f or sedent ar y wor k, but wi t h r est r i ct i ons on pr ol onged

st andi ng, si t t i ng, and wal ki ng.

I n cont r ast , i n pr ogr ess not es dated November 4, 2003,

Or t ega' s at t endi ng physi ci an - - Oscar E. Ramos Romn, M. D.

( "Dr . Ramos" ) - - st at ed t hat Or t ega was per manent l y di sabl ed f r om

wor k, not i ng t hat he st i l l suf f er ed f r omsever e neck and back pai n,

scol i osi s, anxi et y, and depr essi on. On November 25, 2003, upon

r evi ewi ng Dr . Ramos' s progr ess not es and t he resul t s of t he FCE,

MCS' s i ndependent medi cal consul t ant - - J os Ocasi o, M. D.

( "Dr . Ocasi o" ) - - r ecommended extendi ng Or t ega' s benef i t s, but

f ur t her r ecommended t hat Or t ega be r eeval uated si x mont hs l ater .

On Apr i l 6, 2004, Or t ega underwent a second FCE, agai n

conduct ed by Dr . Se n. Fol l owi ng t he exami nat i on, Dr . Se n' s

r epor t st at ed t hat Or t ega demonst r at ed ver y i nconsi st ent ef f or t s

t hr oughout t he FCE and that he ref used t o at t empt sever al

act i vi t i es, bot h wei ght ed and non- wei ght ed, whi ch he had per f or med

i n t he pr i or FCE. Dr . Se n agai n concl uded t hat Or t ega had t he

f uncti onal capaci t y f or sedent ar y acti vi t i es, al bei t wi t h

restr i ct i ons .

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On Apr i l 28, 2004, af t er eval uat i ng Dr . Se n' s r epor t ,

Dr . Ocasi o recommended denyi ng Or t ega' s l ong- t er m di sabi l i t y

benef i t s due t o hi s l ack of cooper at i on dur i ng t he second FCE.

However , Dr . Ocasi o l at er r econsi der ed, and he ul t i mat el y

r ecommended appr oval of t he benef i t s. As bef or e, Dr . Ocasi o

f ur t her r ecommended t hat Or t ega undergo r eeval uat i on i n si x mont hs.

On August 19, 2004, MCS i nf ormed Or t ega that , because

Dr . Ramos' s pr ogr ess notes cont i nued t o ment i on Or t ega' s ment al

heal t h, MCS was r eeval uat i ng t he deni al of hi s l ong- t er mdi sabi l i t y

benef i t s r egar di ng hi s ment al and emot i onal st at e. Lui s E. Cnepa,

M. D. ( "Dr . Cnepa") , r evi ewed a copy of t he pr ogr ess not es

r egar di ng Or t ega' s ment al heal t h and concl uded t hat Or t ega' s

emot i onal condi t i ons seemed moderate i n sever i t y. Dr . Cnepa

f ur t her r ecommended t hat Ar l ene Ri ver a- Mass, M. D. ( "Dr . Ri ver a") ,

a psychi at r i st , per f or m an i ndependent medi cal eval uat i on of

Or t ega.

Fol l owi ng t hi s psychi at r i c medi cal eval uat i on conduct ed

on Oct ober 13, 2004, Dr . Ri ver a concl uded t hat , whi l e Or t ega

pr esent ed sympt oms compat i bl e wi t h pani c and mood di sor der , i t

"seem[ ed] t hat t here was a f r ank exaggerat i on of sympt oms. " For

exampl e, Dr . Ri ver a noted t hat Or t ega "cl ai med ext r emel y poor

memor y but di d not pr esent i n t he i nt er vi ew [ wi t h] such

di f f i cul t y. " Dr . Ri ver a opi ned t hat " t he i nf or mat i on he gave

dur i ng t he i nt er vi ew i s unr el i abl e, " and t hat as a resul t , f ur t her

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i nvest i gat i on shoul d occur i n or der t o cor r ect l y di agnose Or t ega' s

ment al and emot i onal sympt oms. Af t er r evi ewi ng Dr . Ri ver a' s

concl usi ons, Dr . Cnepa recommended denyi ng Or t ega l ong- t erm

di sabi l i t y benef i t s based on hi s ment al st at e.

C. The FCE Conducted by Javier Espina on November 16, 2004

On November 16, 2004, Or t ega underwent a t hi r d FCE, whi ch

was conduct ed by J avi er Espi na ( "Espi na") , a physi cal t her api st .

Espi na sai d t hat Or t ega woul d onl y be asked t o per f or m act i vi t i es

he f el t capabl e of compl et i ng; Or t ega coul d st op any t est t hat

caused hi m pai n, i f he so desi r ed. Espi na f ur t her i nst r ucted

Or t ega t o exer t hi s best ef f or t s i n at t empt i ng each act i vi t y.

Fol l owi ng t he FCE, Espi na concl uded t hat Or t ega' s " sympt omat i c

r epor t s and behavi or ar e out of pr opor t i on t o t he obj ect i ve

physi cal f i ndi ngs and t he i dent i f i ed pat hol ogy. "

Speci f i cal l y, Espi na r epor t ed t hat Or t ega: "di d not

compl et e al l t est act i vi t i es"; "decl i ned al l l i f t i ng, car r yi ng,

pushi ng, pul l i ng and cl i mbi ng act i vi t i es, " st at i ng t hat he di d not

want t o r i sk f ur t her i nj ur y; and "demonst r at ed a consi st ent sub-

maxi mal ef f or t t hr oughout t hi s eval uat i on. " For exampl e, Espi na' s

r epor t obser ved t hat Or t ega "decl i ned t he (Ri ght Leg) Si t t i ng Leg

Rai si ng" t est , st at i ng t hat "he coul dn' t f l ex hi s Ri ght Knee, "

al t hough t he t est i ng cent er ' s " vi deo cl ear l y shows t hat Mr . Or t ega

[ was] abl e t o Si t and Fl ex hi s Ri ght Knee" whi l e seat ed i n t he

wai t i ng r oom.

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Espi na f ur t her determi ned t hat Or t ega "demonst r ated a

r egi onal , non- speci f i c" t est i ng pat t er n "t hat i s not consi st ent

wi t h an or gani c pai n syndr ome. " Or t ega' s scores on t est i ng

pr ot ocol s " i ndi cat [ ed] t hat t her e i s a non- or gani c component t o hi s

pai n, medi cal i mpai r ment and di sabi l i t y. " Dur i ng t hi s FCE, Or t ega

passed onl y thr ee out of t went y- one "val i di t y cr i t er i a, " whi ch ar e

used t o obj ect i vel y det er mi ne whet her a pat i ent i s honest l y t r yi ng

hi s or her best t o compl et e the var i ous physi cal t asks r equi r ed f or

t he eval uat i on. Accor di ng t o Espi na, t hi s f our t een- per cent pass

r at e "suggest s ver y poor ef f or t or vol unt ar y sub maxi mal ef f or t ,

whi ch i s not necessar i l y r el at ed t o pai n, i mpai r ment or

di sabi l i t y. " 4

4 Espi na' s r epor t not es t hat a per son' s "Val i di t y Pr of i l e i scompr i sed of a cohor t of i ndi vi dual t est s t hat col l ect i vel y hel p

det er mi ne whet her or not t he pat i ent i s exer t i ng t hei r best ef f or tdur i ng al l of t he FCE t est s. " Fai l i ng t he t est i ndi cat es t hat t hepat i ent has "not exer t ed t hei r best ef f or t . " Because " t he pat i enti s not asked t o per f or m t asks f or whi ch t hey do not have t hephysi cal abi l i t y" and "t he t est dat a shoul d r eveal " i f t he pat i entdoes not have such abi l i t y, " t hen t he onl y r eason f or not passi ngt he over al l Val i di t y Pr of i l e i s t hat t he pat i ent was not mot i vat edt o cooper at e wi t h t he eval uat i on pr ocess and exer t t hei r bestef f or t . " Accor di ng t o t he r epor t , "f ai l i ng t he Over al l Val i di t yPr of i l e i s vi ewed as a vol unt ar y act of non- compl i ance wi t h t het est i ng pr ocess and t he pr of essi onal s who r equest ed t he t est . "

Wi t h r espect t o t he number of val i di t y cr i t er i a passed, a r at eof 90- 100% i ndi cat es " Excel l ent Ef f or t , " 80- 89% i ndi cat es "GoodEf f or t , " 70- 79% i ndi cat es "Fai r Ef f or t , " 60- 69% i ndi cat es "PoorEf f or t , " and l ess t han 60% i ndi cat es "Ver y Poor Ef f or t . " Or t egapassed onl y 14% of t he val i di t y cri t er i a, l eadi ng Espi na t oconcl ude t hat hi s per f ormance was "I nval i d" and demonst r ated "VeryPoor Ef f or t . "

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Espi na obser ved t hat "Or t ega' s movement pat t erns i mpr oved

si gni f i cant l y by di st r act i on" when compar ed t o t he abi l i t y he

demonst r ated dur i ng di r ect obser vat i on. Such a f i ndi ng suggest s

t hat Or t ega was "at t empt i ng t o cont r ol t he t est r esul t s t o

demonst r at e mor e pai n and di sabi l i t y t han [ wer e] act ual l y pr esent . "

As one exampl e, i n eval uat i ng Or t ega' s gai t , Espi na not ed t hat

Or t ega' s movement s whi l e wal ki ng exhi bi t ed a "poor cor r el at i on wi t h

t he pai n r at i ng" and t hat hi s "behavi or i s i nappr opr i at e. " I n

concl udi ng hi s det ai l ed anal ysi s, Espi na r epor t ed t hat Or t ega' s

behavi or and physi cal per f or mance wer e not consi st ent wi t h hi s

st at ed sympt oms and al l eged di sabi l i t y. I nst ead, Espi na concl uded

t hat Or t ega was, i n f act , exagger at i ng hi s sympt oms and

di sabi l i t i es. 5

D. The Termination of Ortega's Benefits

On November 22, 2004, af t er r evi ewi ng Espi na' s r eport and

Dr . Ramos' s updated pr ogr ess notes, Dr . Ocasi o r ecommended denyi ng

Or t ega l ong- t er mdi sabi l i t y benef i t s due t o hi s l ack of cooper at i on

dur i ng t he t hi r d FCE. Accor di ngl y, MCS not i f i ed Or t ega t hat ,

pur suant t o t he Pl an' s t er ms, Or t ega' s l ack of cooper at i on i n t he

eval uat i on pr ocess j ust i f i ed t he t er mi nat i on of hi s l ong- t er m

di sabi l i t y benef i t s .

5 The r eport st ates that "The Movement Pat t erns and Behavi or Ar eNot Consi st ent wi t h the Sympt oms and Di sabi l i t y, " and concl udest hat "Tr ue Sympt om/ Di sabi l i t y Exagger at i on Exi st s. "

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On J anuary 12, 2005, Or t ega appeal ed t hat deci si on. He

at t ached a l et t er dated December 10, 2004, i n whi ch Dr . Ramos

concl uded t hat , i n hi s pr of essi onal opi ni on, Or t ega was " t ot al l y

and permanent l y di sabl ed t o work. " On J anuary 19, 2005, af t er

r evi ewi ng Or t ega' s r ecor ds - - i ncl udi ng t he updat ed pr ogr ess not es

f r om al l of Or t ega' s at t endi ng physi ci ans - - Dr . Ocasi o

never t hel ess r ecommended t he deni al of Or t ega' s appeal because

Or t ega pr esent ed no new evi dence t hat woul d support a di f f erent

r ecommendat i on.

Or t ega r equest ed a second appeal of hi s cl ai m on

Febr uary 24, 2005. He at t ached Dr . Ramos' s si gned medi cal

cer t i f i cat e, whi ch st at ed t hat Or t ega' s physi cal condi t i on was

pr ogr essi ve, he st i l l suf f er ed f r om sever e back pai n, and he was

i ncapabl e of per f ormi ng t he t est s r equest ed by MCS.

On March 20, 2005, af t er r evi ewi ng Or t ega' s second

appeal , t he J ohnson & J ohnson Di sabi l i t y Revi ew Commi t t ee uphel d

t he deci si on t o t er mi nat e hi s l ong- t er m di sabi l i t y benef i t s f or

f ai l i ng t o cooper at e wi t h t he eval uat i ons of hi s cont i nui ng

di sabi l i t y. Addi t i onal l y, i n i t s r evi ew of Or t ega' s r ecor d, t he

Di sabi l i t y Revi ew Commi t t ee f ound no ci r cumst ances j ust i f yi ng or

expl ai ni ng Or t ega' s l ack of cooper at i on or hi s exagger at i on of

sympt oms. Last l y, t he commi t t ee f ound t hat Or t ega hi msel f f ai l ed

t o pr ovi de any expl anat i on f or hi s " l ack of cooper at i on/ compl i ance

i n compl et i ng t he t est s t hat wer e i ncl uded i n t he FCE. "

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E. Procedural History

Bef or e t he di st r i ct cour t , Or t ega ar gued t hat t he

Appel l ees ar bi t r ar i l y and capr i ci ousl y deni ed hi s benef i t s due

under ERI SA, and he request ed a j udgment order i ng t he rei nst atement

of t hose benef i t s as wel l as t he r et r oact i ve payment of past

benef i t s. 6 Af t er gr ant i ng Appel l ees' mot i on t o pr oceed wi t h t he

mat t er as an admi ni st r at i ve appeal , t he di st r i ct cour t gr ant ed

Appel l ees' mot i on f or j udgment on t he admi ni st r at i ve r ecor d and

di smi ssed Or t ega' s cl ai m wi t h pr ej udi ce on Mar ch 26, 2013.

I n so doi ng, t he di st r i ct cour t hel d t hat t he r ecor d

pr ovi ded t he pl an admi ni st r at or ampl e basi s f or f i ndi ng t hat Or t ega

di d not cooperate f ul l y dur i ng the FCE hel d on November 20, 2004,

and t hus Appel l ees di d not act ar bi t r ar i l y and capr i ci ousl y i n

t er mi nat i ng Or t ega' s benef i t s. Thi s appeal f ol l owed.

II. Analysis

We gener al l y revi ew t he deni al of benef i t s under an ERI SA

pl an de novo. See Fi r est one Ti r e & Rubber Co. v. Br uch, 489 U. S.

101, 115 ( 1989) ; Gr oss v. Sun Li f e Assur ance Co. of Can. , 734 F. 3d

1, 11 ( 1st Ci r . 2013) ( st at i ng t hat "[ t ] he def aul t st andar d f or

r evi ewi ng [ ERI SA] benef i t s deci si ons . . . i s de novo") . However ,

wher e t he pl an gr ant s t he pl an admi ni st r at or or anot her f i duci ar y

t he di scr et i onar y aut hor i t y to const r ue t he t er ms of t he pl an or t o

6 Or t ega al so sought an awar d of cost s and at t or ney' s f ees, pl usany ot her avai l abl e damages and r emedi es.

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det er mi ne a par t i ci pant ' s el i gi bi l i t y f or benef i t s, as i s t he case

her e, we appl y a def er ent i al st andar d of r evi ew, uphol di ng t he

admi ni st r at or ' s deci si on "unl ess i t i s ' ar bi t r ar y, capr i ci ous, or

an abuse of di scr et i on. ' " See Cusson v. Li ber t y Li f e Assurance Co.

of Bos. , 592 F. 3d 215, 224 ( 1st Ci r . 2010) ( quot i ng Gannon v.

Met r o. Li f e I ns. Co. , 360 F. 3d 211, 213 ( 1st Ci r . 2004) .

Thi s def er ent i al st andar d of r evi ew, however , i s not

ent i r el y wi t hout t eet h - - i t r equi r es t hat a det er mi nat i on by a

pl an admi ni st r at or "must be ' r easoned and suppor t ed by subst ant i al

evi dence. ' " Col by v. Uni on Sec. I ns. Co. & Mgmt . Co. f or Mer r i mack

Anest hesi a Assocs. Long Ter mDi sabi l i t y Pl an, 705 F. 3d 58, 62 ( 1st

Ci r . 2013) ( quot i ng D & H Ther apy Assocs. , LLC v. Bos. Mut . Li f e

I ns. Co. , 640 F. 3d 27, 35 ( 1st Ci r . 2011) ) . "I n shor t , " such a

det er mi nat i on "must be r easonabl e. " I d. ( ci t i ng Conkri ght v.

Fr ommert , 559 U. S. 506, 521- 22 ( 2010) ) .

Speci f i cal l y, "t he quest i on i s ' not whi ch si de we bel i eve

i s r i ght , but whet her t he [ admi ni st r at or ] had subst ant i al

evi dent i ar y gr ounds f or a r easonabl e deci si on i n i t s f avor . ' "

Mat as- Cor r ea v. Pf i zer , I nc. , 345 F. 3d 7, 12 ( 1st Ci r . 2003)

( quot i ng Br i gham v. Sun Li f e of Can. , 317 F. 3d 72, 85 ( 1st Ci r .

2003) ) . Evi dence i s deemed subst ant i al "when i t i s reasonabl y

suf f i ci ent t o suppor t a concl usi on. " Cusson, 592 F. 3d at 230

( quot i ng Wr i ght v. R. R. Donnel l ey & Sons Co. Gr p. Benef i t s Pl an,

402 F. 3d 67, 74 ( 1st Ci r . 2005) ) . Mor eover , so l ong as subst ant i al

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evi dence suppor t s t he pl an admi ni st r at or ' s deci si on, t he deci si on

i s not r endered unr easonabl e by the mere exi st ence of evi dence to

t he cont r ar y. I d.

Al t hough a pl an admi ni st r at or "may not ar bi t r ar i l y ref use

t o cr edi t a cl ai mant ' s r el i abl e evi dence, i ncl udi ng t he opi ni ons of

a t r eat i ng physi ci an, " we do not r equi r e admi ni st r at or s t o

aut omat i cal l y gr ant "speci al wei ght " t o t he opi ni on of a cl ai mant ' s

chosen pr ovi der . Bl ack & Decker Di sabi l i t y Pl an v. Nor d, 538 U. S.

822, 834 ( 2003) ; see al so Medi na v. Met r o. Li f e I ns. Co. , 588 F. 3d

41, 46 ( 1st Ci r . 2009) ( "A pl an admi ni st r at or i s not obl i gat ed t o

accept or even t o gi ve par t i cul ar wei ght t o t he opi ni on of a

cl ai mant ' s t r eat i ng physi ci an. " ( quot i ng Mor al esAl ej andr o v. Med.

Car d Sys. , I nc. , 486 F. 3d 693, 700 ( 1st Ci r . 2007) ) ) . Si mi l ar l y,

cour t s may not i mpose "a di scr ete bur den of expl anat i on" on pl an

admi ni st r at or s " when t hey cr edi t r el i abl e evi dence t hat conf l i ct s

wi t h a t r eat i ng physi ci an' s eval uat i on. " Bl ack & Decker , 538 U. S.

at 834. "Consequent l y, ' i n t he pr esence of conf l i ct i ng evi dence,

i t i s ent i r el y appr opr i at e f or a r evi ewi ng cour t t o uphol d t he

deci si on of t he ent i t y ent i t l ed t o exer ci se i t s di scr et i on. ' "

Medi na, 588 F. 3d at 46 ( quot i ng Gannon, 360 F. 3d at 216) .

On appeal , Or t ega r ai ses sever al ar gument s i n suppor t of

hi s posi t i on t hat t he di st r i ct cour t er r ed i n gr ant i ng j udgment on

t he admi ni st r at i ve r ecor d i n f avor of t he Appel l ees. Speci f i cal l y,

Or t ega ar gues t hat t he di st r i ct cour t er r ed i n concl udi ng t hat he

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di d not cooper at e dur i ng t he t hi r d and f i nal FCE. He f ur t her

asser t s t hat because Espi na i s not a medi cal doct or , t he pl an

admi ni st r at or abused i t s di scr et i on i n credi t i ng Espi na' s opi ni on

over t hat of Dr . Ramos. As expl ai ned bel ow, we f i nd t hat t hese

argument s ar e unpersuasi ve and do not r equi r e reversal .

A. Whether Ortega Did Not Cooperate with a Required Evaluation

Or t ega r el i es heavi l y on hi s asser t i on t hat t he

admi ni st r at i ve r ecor d l acks evi dence t hat he was uncooper at i ve

dur i ng the thi r d and f i nal FCE, whi ch was conduct ed on November 16,

2004. A r evi ew of t he r ecor d, however , r eveal s si gni f i cant

evi dence i n suppor t of t he pl an admi ni st r at or ' s deci si on, as

detai l ed i n t he f oregoi ng summary of t he f actual backgr ound and as

f ur t her expl ai ned bel ow.

Or t ega al so ar gues t hat t he di st r i ct cour t er r ed i n

f i ndi ng t hat because he "had successf ul l y compl et ed eval uat i ons i n

t he past wi t hout bei ng f ound uncooper at i ve, " t he cour t coul d be

"conf i dent t hat he under st ood how t o t r y t he t asks r equest ed of

hi m" dur i ng hi s f i nal FCE, "even i f he coul d not compl et e ever y

one. " Asser t i ng t hat such a f i ndi ng was based on a "sel ect i ve

r evi ew" of t he r ecor d, Or t ega put s f or t h t wo expl anat i ons f or hi s

l ack of cooper at i on dur i ng t he t hi r d FCE. Fi r st , he ar gues that he

di d not compl et e cer t ai n eval uat i on tasks because he was si mpl y

f ol l owi ng t he i nst r uct i ons of bot h Espi na and hi s t r eat i ng

physi ci an, Dr . Ramos, t o avoi d act i ons t hat coul d cause hi mf ur t her

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i nj ur y. 7 Second, Or t ega notes t hat t here was evi dence on t he

r ecor d showi ng t hat he was cooper at i ve dur i ng ear l i er FCEs. He

f ur t her ar gues t hat hi s medi cal condi t i on i s degener at i ve, and t hat

i t i s t her ef or e onl y nat ur al t hat he woul d not be abl e t o compl et e

subsequent t est s as wel l as he had compl et ed pr i or eval uat i ons.

These ar gument s mi sunder st and bot h t he di st r i ct cour t ' s

r easoni ng as wel l as the r el evant st andar d. I mmedi at el y af t er

f i ndi ng t hat Or t ega knew how t o compl ete the FCE t asks, t he

di st r i ct cour t f ur t her expl ai ned: "[ i ] n any event , t he poi nt i s not

whether every obser ver woul d have agr eed Or t ega- Candel ar i a was

uncooper at i ve, but whet her t he pl an admi ni st r at or had suf f i ci ent

evi dence t o concl ude t hat he was uncooper at i ve. " I ndeed, i t i s

cer t ai nl y pl ausi bl e that Or t ega was suf f er i ng f r om a degener at i ve

condi t i on t hat r ender ed hi m unabl e, dur i ng t he t hi r d FCE, t o

per f or mphysi cal t asks t hat he had pr evi ousl y been abl e t o per f or m

i n pr i or FCEs. And i t i s f ur t her pl ausi bl e t hat Or t ega' s ref usal

t o per f or m cer t ai n t asks was not because he was f ei gni ng hi s

i nj ur i es or exaggerat i ng hi s sympt oms, but was because he was

ei t her exper i enci ng sever e pai n or f ol l owi ng hi s physi ci an' s or der s

not t o per f or m movement s t hat wer e l i kel y t o f ur t her i nj ur e hi m.

7 Accor di ng t o Or t ega, Dr . Ramos i nf or med hi mt hat he shoul d avoi dcer t ai n acti vi t i es, i ncl udi ng: "si t t i ng- st andi ng, " bendi ng,wal ki ng, pul l i ng, l i f t i ng, car r yi ng, and oper at i ng f oot - pedal s.Presumabl y, Or t ega r easons t hat t hi s medi cal advi ce const i t ut ed anabsol ut e pr ohi bi t i on, such t hat he shoul d avoi d even at t empt i ngsuch act i vi t i es dur i ng medi cal or f unct i onal eval uat i ons.

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Yet t he oper at i ve st andar d i s not whet her Or t ega has put

f or t h a pl ausi bl e nar r at i ve, or whet her we ar e mor e persuaded by

Or t ega' s account of t he f act s t han by Appel l ees' ver si on. See

Mat as- Cor r ea, 345 F. 3d at 12 ( " [ T] he quest i on i s ' not whi ch si de

we bel i eve i s r i ght . . . . ' " ( quot i ng Br i gham, 317 F. 3d at 85) ) .

Rat her , we ask whet her t he pl an admi ni st r at or had evi dence that i s

" r easonabl y suf f i ci ent " t o suppor t i t s det er mi nat i on. See Cusson,

592 F. 3d at 230 ( quot i ng Wr i ght , 402 F. 3d at 74) .

A r evi ew of t he admi ni st r at i ve r ecor d r eveal s t hat such

evi dence was pr esent her e. Or t ega' s assert i on t hat he was

physi cal l y unabl e t o compl et e some of t he t est s does not vi t i at e

Espi na' s f i ndi ngs t hat Or t ega f ai l ed t o cooper at e by put t i ng f or t h

hi s best ef f or t s t o at t empt t he t asks request ed dur i ng t he t hi r d

FCE. Whi l e Espi na di d st at e t hat Or t ega woul d not be asked t o

compl et e any t est he f el t unabl e t o per f or m and t hat he coul d st op

any t ask i f pai n occur r ed, Espi na f ur t her i nst r uct ed Or t ega t o

exer t hi s best ef f or t on each t est absent any i ncr eased pai n.

Despi t e t hi s i nst r ucti on, t he r esul t s of Or t ega' s f i nal

FCE "suggest [ ed] ver y poor ef f or t or vol unt ar y sub maxi mal ef f or t ,

whi ch i s not necessar i l y r el at ed t o pai n, i mpai r ment or

di sabi l i t y. " Espi na' s r esul t s suggest ed t hat Or t ega was

"at t empt i ng t o cont r ol t he t est r esul t s t o demonst r at e mor e pai n

and di sabi l i t y" t han he was act ual l y exper i enci ng. Or t ega r ef used

t o per f orm many of t he t asks. Hi s movement s whi l e wal ki ng di d not

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cor r espond wi t h hi s pai n r epor t s. He f ai l ed ei ght y- si x per cent of

t he val i di t y cr i t er i a, whi ch ar e used t o det er mi ne whet her a

pat i ent i s honest l y usi ng hi s or her best ef f or t s t o per f or m t he

r equi r ed physi cal t est s.

Vi deo f oot age f ur t her suppor t s t he concl usi on t hat Or t ega

was not cooper at i ve; t he vi deo shows Or t ega f l exi ng hi s r i ght knee

i n t he wai t i ng r oompr i or t o hi s f i nal FCE - - an act whi ch he l at er

r ef used t o per f or m dur i ng t he FCE i t sel f . Espi na' s eval uat i on

ul t i mat el y det er mi ned t hat Or t ega' s behavi or and physi cal

per f ormance were not consi st ent wi t h hi s r epor t ed sympt oms and

al l eged di sabi l i t y; Espi na thus concl uded t hat Or t ega was

exaggerat i ng hi s symptoms.

Mor eover , Espi na' s r epor t was not t he f i r st i ndi cat i on i n

t he r ecor d t hat Or t ega was exaggerat i ng hi s sympt oms. Dr . Se n

r epor t ed t hat Or t ega demonst r at ed a "ver y r est r i ct ed" or "sub-

mi ni mal " ef f or t dur i ng hi s f i r st FCE. Addi t i onal l y, Dr . Se n

obser ved t hat Or t ega f r equent l y shi f t ed hi s wei ght on ei t her l eg

despi t e compl ai ni ng of maj or pai n sympt oms wi t h r espect t o onl y hi s

r i ght l eg. Or t ega al so demonst r at ed i nconsi st ency i n hi s

per f or mance of a hand- gr i p t est and r ef used t o per f or msome tasks.

Dur i ng t he second FCE conduct ed by Dr . Se n, Or t ega

demonst r at ed ver y i nconsi st ent ef f or t s and r ef used t o per f or m

sever al t est s, i ncl udi ng some that he had pr evi ousl y compl et ed i n

t he f i r st FCE. On t hat basi s, Dr . Ocasi o i ni t i al l y r ecommended

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denyi ng Or t ega' s benef i t s due t o t hi s l ack of cooper at i on.

Fur t her mor e, f ol l owi ng a psychi at r i c eval uat i on, Dr . Ri ver a

det er mi ned t hat Or t ega gave "unr el i abl e" i nf or mat i on and di spl ayed

"exaggerat i on of sympt oms" dur i ng hi s exami nat i on.

Wi t h t he f or egoi ng f act s i n mi nd, we concl ude t hat t he

r ecor d cont ai ns evi dence r easonabl y suf f i ci ent t o suppor t a

det er mi nat i on that Or t ega was uncooper at i ve dur i ng hi s eval uat i on.

See Cusson, 592 F. 3d at 230 ( deemi ng evi dence subst ant i al "when i t

i s r easonabl y suf f i ci ent t o suppor t a concl usi on" ( quot i ng Wr i ght ,

402 F. 3d at 74) ) .

The Pl an' s t er ms r equi r e t hat Or t ega cooperat e dur i ng

eval uat i ons of hi s di sabi l i t y status; wi t hout such cooper at i on, t he

pl an admi ni st r at or r et ai ns t he r i ght t o r educe or t er mi nat e hi s

benef i t s. 8 Ther ef or e, because t he evi dence on t he admi ni st r at i ve

r ecor d permi t s a r easonabl e f i ndi ng t hat Or t ega was uncooper at i ve

dur i ng hi s t hi r d FCE, t he Appel l ees' deci si on t o t er mi nat e Or t ega' s

benef i t s cannot pr oper l y be deemed ar bi t r ar y and capr i ci ous or an

abuse of di scr et i on. See Mor al es- Al ej andr o, 486 F. 3d at 700

8 "The Pl an Admi ni st r at or . . . r eser ves t he r i ght t o r educe ort er mi nat e benef i t s at any t i me i f i t i s det er mi ned t hat aPar t i ci pant no l onger qual i f i es f or benef i t s under t he t er ms,condi t i ons, and def i ni t i ons of t he Pl an. Wi t hout l i mi t i ng t he

f or egoi ng, f ai l ur e or r ef usal by a Par t i ci pant t o . . . cooper at ewi t h any ot her pr ocedur es, eval uat i on, i nvest i gat i on or audi t . . .[ or ] cooper at e wi t h r espect t o t he eval uat i on of a Par t i ci pant ' sTot al Di sabi l i t y or cont i nued Tot al Di sabi l i t y . . . shal lconst i t ut e gr ounds f or t er mi nat i on of benef i t s under t he Pl an att he sol e di scret i on of t he Pl an Admi ni st r at or or i t s aut hor i zedr epr esent at i ve. "

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( uphol di ng t he pl an admi ni st r at or ' s deci si on t o t er mi nat e

di sabi l i t y benef i t s wher e evi dence on t he admi ni st r at i ve r ecor d

r easonabl y suppor t ed such a deci si on) ; Leahy v. Raytheon Co. , 315

F. 3d 11, 19- 20 ( 1st Ci r . 2002) ( hol di ng t hat wher e a pl an

admi ni st r at or makes a deci si on suppor t ed by subst ant i al evi dence,

t hat deci si on cannot pr oper l y be deemed ar bi t r ar y and capr i ci ous) .

B. Whether Appellees Improperly Relied on Non-Medical Evidence

Or t ega f ur t her cl ai ms t hat t he deni al of hi s benef i t s was

i mpr oper because t he pl an admi ni st r at or ' s deci si on r est ed on t he

f i ndi ngs of a physi cal t her api st r at her t han t hose of a physi ci an.

Accor di ng t o Or t ega, t he Pl an' s t er ms r equi r e a medi cal eval uat i on

t o be conduct ed by a physi ci an pr i or t o t he deni al of l ong- t er m

di sabi l i t y benef i t s. On t hat basi s, i n Or t ega' s vi ew, Espi na' s

f i ndi ngs cannot pr oper l y suppor t t he deni al of hi s benef i t s because

Espi na i s not a physi ci an, and t hus, coul d not per f or m a "medi cal "

eval uat i on as r equi r ed by t he Pl an.

Thi s ar gument f ai l s t o car r y t he day. Under t he Pl an' s

t er ms, f or pur poses of eval uat i ng a cl ai m, t he pl an admi ni st r at or

may r equi r e a cl ai mant l i ke Or t ega t o undergo an exami nat i on

conduct ed by a "Pl an Provi der . " 9 A "Pl an Provi der" means "a

Pr ovi der sel ect ed by . . . t he Pl an Admi ni st r at or t o exami ne or

9 Ar t i cl e I V of t he Pl an, i n r el evant par t , stat es: "[ i ] neval uat i ng t he cl ai m, t he Cl ai ms Ser vi ce Or gani zat i on may requi r eaddi t i onal i nf or mat i on f r om t he at t endi ng Pr ovi der ( s) or ar r angef or an exami nat i on by a Pl an Provi der at no cost t o t hePar t i ci pant . "

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eval uat e t he Par t i ci pant ' s medi cal condi t i on i n or der t o det er mi ne

hi s/ her Tot al Di sabi l i t y or cont i nui ng Tot al Di sabi l i t y . . . . "

A "Pr ovi der , " i n t ur n, i s def i ned as "a per son who, wi t h r espect t o

any Par t i ci pant : ( a) i s l egal l y l i censed t o pr ovi de heal t h car e t o

t he Par t i ci pant ; ( b) pr ovi des such car e wi t hi n t he scope of hi s or

her l i cense; and ( c) i s not a r el at i ve or dependent of t he

Par t i ci pant . "

Or t ega does not argue t hat Espi na, as a physi cal

t her api st , i s not "l egal l y l i censed t o pr ovi de heal t h car e" t o hi m.

Nor does Or t ega ar gue that conduct i ng the FCE di d not const i t ut e

"car e wi t hi n t he scope" of Espi na' s l i cense, or t hat a physi cal

t her api st cannot exami ne or eval uat e a per son' s "medi cal condi t i on"

i n or der t o det er mi ne hi s or her di sabi l i t y st at us. Rat her , Or t ega

si mpl y ar gues t hat because Espi na i s not a physi ci an, t he FCE di d

not const i t ut e a "medi cal " eval uat i on.

Or t ega f ai l s t o poi nt t o any l anguage i n t he Pl an

r equi r i ng a "Pr ovi der " t o be a medi cal doct or , or st at i ng t hat an

exami nat i on cannot be conduct ed by a physi cal t her api st or can onl y

be conduct ed by a physi ci an. I nst ead, Or t ega mer el y r epeat s hi s

asser t i ons t hat an FCE i s not a "medi cal " eval uat i on, and t hat onl y

a physi ci an can per f or m a "medi cal " exami nat i on. We have

r epeat edl y hel d that we may di sr egard such bare, unsupport ed

asser t i ons on appeal . See, e. g. , Uni t ed St at es v. Del gado- Mar r er o,

744 F. 3d 167, 203 ( 1st Ci r . 2014) ( st at i ng t hat t he cour t need not

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consi der "concl usor y al l egat i ons" or "bar e asser t i ons" i n an

appel l ant ' s br i ef ) ; Uni t ed St at es v. Del l osant os, 649 F. 3d 109, 126

n. 18 ( 1st Ci r . 2011) ( deemi ng an i ssue wai ved i n l i ght of t he

par t y' s " per f unct or y t r eat ment " of a case and " l ack of devel oped

ar gument at i on") .

Even assumi ng t hat Or t ega had not wai ved t hi s i ssue f or

want of devel oped ar gument , t he Pl an' s t ext does not suppor t hi s

posi t i on. Had t he Pl an' s dr af t er s i nt ended eval uat i ons t o be

per f or med sol el y by medi cal doct or s, t hey coul d have sel ect ed t he

speci f i c t er ms "physi ci an" or "doct or " r at her t han a gener al ,

i ncl usi ve t er m such as "pr ovi der . " Mor eover , t her e i s st r ong

suppor t i n Puer t o Ri co l aw f or t he asser t i on t hat a l i censed

physi cal t her api st i s a per son who "i s l egal l y l i censed t o pr ovi de

heal t h car e, " as requi r ed by t he Pl an. I n a Puer t o Ri co st at ut e

gover ni ng t he l i censi ng of physi cal t her api st s, "physi cal t her apy"

i s def i ned i n par t as t he "t r eat ment " or "pr event i on" of any human

"di sabi l i t y, i nj ur y, i l l ness or ot her condi t i on of heal t h, " "as

wel l as t he admi ni st r at i on of neur omuscul ar t est s t o ai d t he

di agnosi s or t r eat ment of any human condi t i on. " P. R. Laws Ann.

t i t . 20, 241( 1) .

The r equi r ement s f or a l i cense t o pract i ce physi cal

t her apy i n Puer t o Ri co al so i ncl ude t he compl et i on of "a cour se of

st udy at a school of physi cal t her apy r ecogni zed by t he . . .

Amer i can Medi cal Associ at i on and/ or t he Amer i can Associ at i on of

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Physi cal Ther apy. " I d. 245. Fi nal l y, accor di ng t o t he Amer i can

Associ at i on of Physi cal Ther apy, physi cal t her api st s ar e "l i censed

heal t h car e pr of essi onal s who can hel p pat i ent s r educe pai n and

i mpr ove or r est or e mobi l i t y. " 10 Thus, t he pl an admi ni st r at or had

a r easonabl e basi s f or i nt er pr et i ng t he gener al t er m"pr ovi der " t o

encompass l i censed physi cal t her api st s i n Puer t o Ri co.

Moreover , Or t ega has admi t t ed - - and t he Pl an' s t erms

expl i ci t l y st at e - - t hat t he pl an admi ni st r at or has t he r i ght t o

r equi r e one or mor e FCEs at any t i me dur i ng t he cl ai m eval uat i on

pr ocess. I n a sect i on t i t l ed "Excl usi ons f r om Payment of

Benef i t s, " t he Pl an f ur t her pr ovi des t hat , "[ n] ot wi t hst andi ng any

ot her pr ovi si on of t hi s Pl an, " "no benef i t shal l be payabl e" i f a

par t i ci pant "f ai l s or r ef uses t o cooper at e . . . wi t h r espect t o

any pr ocedur e, eval uat i on, i nvest i gat i on or audi t i n connect i on

wi t h t hi s Pl an . . . whet her per f or med by the Pl an Admi ni st r at or

. . . or any ot her del egat e of t he Pl an Admi ni st r at or . " Thi s

excl usi onar y pr ovi si on does not r equi r e an "eval uat i on" or

" i nvest i gat i on" t o be a "medi cal " exami nat i on or eval uat i on. Nor

does t he pr ovi si on r equi r e that t he per son conduct i ng an eval uat i on

be a "pr ovi der " as def i ned i n t he Pl an; i nst ead, t he eval uat i on may

be conduct ed by "any ot her del egat e" of t he pl an admi ni st r at or .

10 Am. Physi cal Ther apy Ass ' n, Who Ar e Physi cal Ther api st s?,ht t p: / / www. apt a. or g/ About PTs/ ( l ast updat ed May 23, 2013) .

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Or t ega has al so conceded t hat t he Pl an gr ant s t he pl an

admi ni st r at or t he di scr et i onar y aut hor i t y t o const r ue and i nt er pr et

t he Pl an' s t er ms. On t hat basi s, Or t ega agr ees, as he must , t hat

t he appl i cabl e st andar d of r evi ew i s t he def er ent i al ar bi t r ar y- and-

capr i ci ous or abuse- of - di scr et i on st andar d. See Cusson, 592 F. 3d

at 224; Gr oss, 734 F. 3d at 11. Accor di ngl y, we cannot say t hat i t

was ar bi t r ar y, capr i ci ous, or an abuse of di scret i on f or t he pl an

admi ni st r at or t o i nt er pr et t he Pl an' s l anguage as per mi t t i ng t he

t er mi nat i on of benef i t s based on FCE det er mi nat i ons t hat Or t ega was

exaggerat i ng hi s sympt oms and was not cooperat i ng wi t h hi s

eval uat i on. Ther ef or e, Or t ega' s ar gument s on t hi s i ssue ar e

unavai l i ng.

C. The Effect of Appellees' Failure to Adopt Dr. Ramos's Opinion

Last l y, Or t ega r el i es on t he opi ni on of hi s t r eat i ng

physi ci an, Dr . Ramos, t o est abl i sh t hat he was " t ot al l y di sabl ed, "

i n or der t o di scredi t Espi na' s f i ndi ngs t hat Or t ega was

uncooper at i ve dur i ng t he t hi r d FCE. Or t ega asser t s that i t was

er r or f or t he pl an admi ni st r at or t o cr edi t Espi na' s assessment over

t hat of Dr . Ramos.

Or t ega i s cor r ect t hat a pl an admi ni st r at or "may not

ar bi t r ar i l y r ef use t o credi t " t he opi ni on of a cl ai mant ' s t r eat i ng

physi ci an. See Bl ack & Decker , 538 U. S. at 834 ( emphasi s added) .

Her e, however , Or t ega has f ai l ed t o est abl i sh t hat t her e was any

such ar bi t r ar y r ej ect i on of Dr . Ramos' s opi ni on or , i ndeed, of any

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ot her r el i abl e evi dence suppor t i ng Or t ega' s posi t i on. And

Appel l ees were under no mandate t o gr ant "speci al wei ght " t o t he

opi ni ons of Or t ega' s at t endi ng physi ci an. See i d.

Essent i al l y, Or t ega asks us t o hol d t hat t he opi ni on of

Dr . Ramos, as Or t ega' s at t endi ng physi ci an, necessar i l y cont r ol s

over cont r adi ct or y evi dence i n t he r ecor d. Such a posi t i on,

however , f l i es i n t he f ace of our pr ecedent . See Ri char ds v.

Hewl et t - Packar d Cor p. , 592 F. 3d 232, 240 ( 1st Ci r . 2010) ( " [ T] he

opi ni on of t he cl ai mant ' s t r eat i ng physi ci an, whi ch was consi der ed,

i s not ent i t l ed t o speci al def er ence. ") ( quot i ng Or ndor f v. Paul

Rever e Li f e I ns. Co. , 404 F. 3d 510, 526 ( 1st Ci r . 2005) ) ; Mor al es-

Al ej andr o, 486 F. 3d at 700 ( " [ A] pl an admi ni st r at or i s not

obl i gat ed t o accept or even t o gi ve par t i cul ar wei ght t o t he

opi ni on of a cl ai mant ' s t r eat i ng physi ci an. ") .

Or t ega ci t es sever al cases f r om ot her j ur i sdi cti ons i n

suppor t of hi s ar gument t hat an at t endi ng physi ci an' s medi cal

eval uat i on shoul d be gi ven more wei ght t han an FCE per f ormed by a

physi cal t her api st or anot her non- physi ci an. Or t ega' s r el i ance on

t hese cases i s mi spl aced. The f i r st di st r i ct cour t case r el i ed

upon by Or t ega was l ater r emanded by t he El event h Ci r cui t and t hen

subsequent l y vacat ed upon t he par t i es' set t l ement . See Ri dge v.

Har t f or d Li f e & Acci dent I ns. Co. , 339 F. Supp. 2d 1323 ( M. D. Fl a.

2004) , vacated, No. 8: 03CV1871T26EAJ , 2005 WL 889964 ( M. D. Fl a.

Apr . 7, 2005) . Even i f Ri dge wer e not a vacat ed di st r i ct cour t

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case f r omanot her ci r cui t , t he f actual pr edi cat e f or i t s hol di ng i s

i napposi t e. I n Ri dge, t he cour t f ound t hat "[ n] ot hi ng i n t he Pl an

def i nes an FCE, and not hi ng i n t he Pl an per mi t s [ t he i nsur er ] t o

r equi r e an FCE. " 339 F. Supp. 2d at 1336. Her e, i n cont r ast , t he

Pl an expl i ci t l y pr ovi des t hat " [ o] ne or mor e . . . Funct i onal

Capaci t y Exami nat i on( s) ( FCE) may be r equi r ed at any t i me dur i ng

t he cl ai m eval uat i on pr ocess. "

Or t ega next r el i es upon Lamanna v. Speci al Agent s Mut .

Benef i t s Ass' n, 546 F. Supp. 2d 261 (W. D. Pa. 2008) , and St up v.

UNUM Li f e I ns. Co. of Am. , 390 F. 3d 301 ( 4t h Ci r . 2004) , abr ogat ed

by Wi l l i ams v. Met r o. Li f e I ns. Co. , 609 F. 3d 622 ( 4t h Ci r . 2010) .

Or t ega emphasi zes t he Lamanna cour t ' s s t atement t hat " t est s of

st r engt h such as a f unct i onal capaci t y eval uat i on ( ' FCE' ) can

nei t her pr ove nor di sprove cl ai ms of di sabl i ng pai n. " See Lamanna,

546 F. Supp. 2d at 296. However , Lamanna does not advance Or t ega' s

cause f or at l east t hr ee r easons.

Fi r st , t he cour t concl uded t he sent ence hi ghl i ght ed by

Or t ega as f ol l ows: FCEs do not "necessar i l y pr esent a t r ue pi ct ur e

i n cases i nvol vi ng f i br omyal gi a where the sympt oms ar e known t o wax

and wane, t her eby causi ng t est r esul t s pot ent i al l y t o be

unr eal i st i c measur es of a per son' s abi l i t y t o wor k on a r egul ar ,

l ong- t er m basi s. " I d. The r ecor d her e, however , does not

est abl i sh t hat Or t ega suf f er s f r om f i br omyal gi a. Second, t he

Lamanna cour t al so expl ai ned t hat " [ w] hi l e the amount of f at i gue or

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pai n an i ndi vi dual exper i ences may be ent i r el y subj ect i ve, t he

ext ent t o whi ch t hose condi t i ons l i mi t her f unct i onal capabi l i t i es

can be obj ect i vel y measur ed. " I d. at 296. Her e, t he t hr ee FCEs

sought t o obj ect i vel y measur e t he l i mi t at i ons of Or t ega' s

f unct i onal capabi l i t i es, and al l t hr ee FCEs i nvol ved at l east some

i ndi cat i on t hat Or t ega was exaggerat i ng hi s sympt oms or was not

exer t i ng hi s best ef f or t s.

Thi r d, t he Lamanna cour t f ound t hat t her e wer e "numer ous

pr ocedur al i nconsi st enci es whi ch demonst r at e rel i ance on medi cal

r evi ews based on i ncompl et e recor ds, f ai l ur e t o adequat el y anal yze

t he r epor t s of Pl ai nt i f f ' s tr eat i ng physi ci ans, and unr eal i st i c

demands f or obj ect i ve evi dence of f i br omyal gi a and chr oni c f at i gue

syndr ome. " I d. at 288. The cour t f ur t her f ound t hat t he

admi ni st r at or ' s deci si on was not based on subst ant i al evi dence

because " t her e wer e si gni f i cant omi ssi ons, mi s- i nt er pr et at i ons, and

unr easonabl e expect at i ons i n t he repor t s of t he medi cal consul t ant s

upon whi ch [ t he admi ni st r at or ] r el i ed i n r eachi ng i t s concl usi on. "

I d. at 289. By means of cont r ast , i n t he r ecor d bef or e us, we have

i dent i f i ed nei t her "numer ous pr ocedur al i nconsi st enci es" nor

"si gni f i cant omi ssi ons, mi s- i nt er pr et at i ons, and unr easonabl e

expect at i ons" i n t he repor t s upon whi ch t he pl an admi ni st r at or

r el i ed. Cf . i d. at 288- 89.

Or t ega ci t es St up f or t he pr oposi t i on t hat because t he

FCE i n t hat case " l ast ed onl y two and a hal f hour s, . . . t he FCE

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t est r esul t s do not necessar i l y i ndi cat e St up' s abi l i t y t o per f or m

sedent ar y wor k f or an ei ght . . . hour wor kday, f i ve days a week. "

St up, 390 F. 3d at 309. Unl i ke t he i nst ant case, however , t he

cl ai mant i n St up had pr ovi ded t he i nsurer wi t h years of

"subst ant i al medi cal evi dence suppor t i ng her di agnosi s, " i d. at

311, and t he onl y evi dence t o t he cont r ary was "[ a]n equi vocal

opi ni on" t hat was "based on ambi guous t est r esul t s. " I d. at 310.

The physi cal t her api st i n Stup " t wi ce expr ess l y

r ecogni zed t he ambi gui t y of t he FCE r esul t s and hedged her negat i ve

i nt er pr et at i on of t hem. " I d. The t her api st i n t hat case concl uded

her r epor t by war ni ng " t hat i t woul d not be ' pr udent ' t o use the

FCE r esul t s t o det er mi ne St up' s abi l i t y t o per f or m ' speci f i c j ob

dut i es. ' " I d. Her e, on t he ot her hand, Espi na unequi vocal l y

concl uded t hat Or t ega was exaggerat i ng hi s symptoms and

di sabi l i t i es. Espi na r epor t ed t hat Or t ega f ai l ed ei ght een out of

t went y- one val i di t y cri t er i a, i ndi cat i ng a si gni f i cant l ack of

cooper at i on wi t h t he eval uat i on - - a det er mi nat i on t hat const i t ut es

gr ounds f or t er mi nat i on of benef i t s under t he Pl an. Thus, t he

r easoni ng embr aced by St up does not cont r ol t he r esul t here.

Mor eover , al l t hr ee cases r el i ed upon by Or t ega on t hi s

i ssue pr esumed t hat a hei ght ened st andard of r evi ew appl i es i f t he

def endant has a st r uct ur al conf l i ct of i nt er est . See i d. at 307,

311 ( appl yi ng a l ess- def er ent i al st andar d of r evi ew because t he

def endant "acted under a conf l i ct of i nt er est " - - i t s dual r ol e as

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bot h payer of benef i t s and ar bi t er of cl ai ms meant t hat " i t s

deci si on t o deny benef i t s i mpact ed i t s own f i nanci al i nt er est s") ;

Lamanna, 546 F. Supp. 2d at 286 (appl yi ng "a moderatel y hei ght ened

l evel of scrut i ny" because of t he par t i cul ar conf l i ct of i nt er est

caused by the r el at i onshi p bet ween t he cl ai ms admi ni st r at or and t he

i nsur er ) ; Ri dge, 339 F. Supp. 2d at 1334 ( "Because Har t f or d, as

cl ai ms admi ni st r at or , i s al so t he i nsur ance company r esponsi bl e f or

payi ng t he cl ai ms, t he hei ght ened ar bi t r ar y and capr i ci ous st andar d

[ woul d be] appl i cabl e . . . . [ i f ] Har t f or d oper at ed under a

conf l i ct of i nt eres t . " ) .

However , t he Supr eme Cour t has si nce cl ar i f i ed t hat t he

pr esence of a conf l i ct of i nt er est does not al t er t he st andar d of

r evi ew, but r at her i s " but one f act or among many t hat a revi ewi ng

j udge must t ake i nto account . " Met r o. Li f e I ns. Co. v. Gl enn, 554

U. S. 105, 116 ( 2008) . Thus, t he st andar d of r evi ew her e r emai ns

t he def er ent i al abuse- of - di scret i on st andar d. See i d. ; Cusson, 592

F. 3d at 224. Whi l e a conf l i ct of i nt er est " can, under cer t ai n

ci r cumst ances, be accor ded ext r a wei ght i n t he cour t ' s anal ysi s, "

Cusson, 592 F. 3d at 224, Or t ega does not argue t hat such

ci r cumst ances ar e pr esent here.

Cont r ar y t o Or t ega' s ar gument s, we have pr evi ousl y hel d

t hat an admi ni st r at or ' s deci si on t o t er mi nat e di sabi l i t y benef i t s

was not ar bi t r ar y and capr i ci ous even wher e that deci si on was

support ed i n part by an FCE conduct ed by a physi cal t herapi st and

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was di r ect l y cont r adi ct ed by t he cl ai mant ' s t wo t r eat i ng

physi ci ans. See Gannon, 360 F. 3d at 213- 16. The admi ni st r at or ' s

deci si on i n Gannon was suppor t ed by: an FCE conduct ed by a physi cal

t her api st ; t he opi ni on of an " i ndependent medi cal consul t ant who

r evi ewed [ t he cl ai mant ' s] f i l e"; a t r ansf er abl e ski l l s anal ysi s

pr epar ed by a vocat i onal consul t ant ; a sur vei l l ance r epor t ; and t he

deni al of Gannon' s cl ai mf or soci al secur i t y di sabi l i t y benef i t s.

I d. at 213- 15.

As i n t he case at hand, t he FCE i n Gannon " i ndi cated t hat

[ t he cl ai mant ] di d not put f or t h her maxi mum ef f or t dur i ng t he

t est s . . . and t hat her per f or mance was i nconsi st ent i n var i ous

ways. " I d. at 213. The FCE pr ovi ded evi dence t hat t he cl ai mant

was exagger at i ng her sympt oms and that she was physi cal l y capabl e

of per f or mi ng r est r i ct ed wor k act i vi t i es. I d. Gi ven t he f i ndi ngs

of t he FCE and concl usi ons of t he physi cal t her api st , we f ound i t

r easonabl e f or t he pl an admi ni st r at or t o rel y upon t he FCE as

evi dence i n suppor t of i t s det er mi nat i on that Gannon was not

"di sabl ed" under t he Pl an. I d.

Si mi l ar l y, t he Tent h Ci r cui t has hel d t hat t he r esul t s of

t wo FCEs - - bot h admi ni st er ed by physi cal t her api st s - - pr ovi ded

subst ant i al evi dence upon whi ch t he pl an admi ni st r at or coul d have

based i t s deci si on t o deny benef i t s. Buckar dt v. Al ber t son' s,

I nc. , 221 F. App' x 730, 735- 37 ( 10t h Ci r . 2007) . Much l i ke Or t ega,

t he pl ai nt i f f i n Buckar dt ar gued t hat t he "FCEs wer e not medi cal

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eval uat i ons" and t hat an FCE admi ni st er ed by a physi cal t her api st

cannot pr ovi de subst ant i al evi dence f or a deci si on t o t er mi nat e

benef i t s. I d. at 735- 36. The Tent h Ci r cui t di sagr eed, r easoni ng

t hat such a posi t i on i s cont r ar y to t he pr evai l i ng pr ecedent i n

sever al ci r cui t s. I d. at 736 ( ci t i ng Gannon, 360 F. 3d at 213, and

J ackson v. Met r o. Li f e I ns. Co. , 303 F. 3d 884, 888 ( 8th Ci r .

2002) ) .

The El event h Ci r cui t has al so addr essed a si mi l ar

ar gument f r om a cl ai mant mai nt ai ni ng t hat an FCE f r om a physi cal

t herapi st shoul d not have been gi ven more wei ght t han t he opi ni on

of t he cl ai mant ' s t r eat i ng physi ci an. See Townsend v. Del t a

Fami l y- Car e Di sabi l i t y & Sur vi vor shi p Pl an, 295 F. App' x 971, 977

( 11t h Ci r . 2008) . I n r ej ect i ng t hi s ar gument , t he El event h Ci r cui t

r easoned t hat "FCEs are rout i nel y conduct ed by physi cal t her api st s"

and "pl an admi ni st r at or s r out i nel y r el y on FCEs. " See i d. ; see

al so Duncan v. Fl eet wood Motor Homes of I nd. , I nc. , 518 F. 3d 486,

489 ( 7t h Ci r . 2008) ; Baker v. Bar nhar dt , 457 F. 3d 882, 885- 86 ( 8t h

Ci r . 2006) . Thus, we have not f ound compel l i ng suppor t f or

Or t ega' s argument t hat a pl an admi ni st r ator cannot r el y on t he

f i ndi ngs of an FCE conduct ed by a physi cal t her api st .

Even i f we wer e i ncl i ned t o accept Or t ega' s t heor y t hat

a medi cal doctor ' s opi ni on must be gi ven more wei ght t han t he

opi ni on of a non- physi ci an, t he recor d her e al so cont ai ns t he

opi ni ons of medi cal doct or s t hat suppor t t he pl an admi ni st r at or ' s

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deci si on. As pr evi ousl y summar i zed, Dr . Se n f ound - - i n t wo

successi ve FCEs - - t hat Or t ega demonst r at ed sub- par ef f or t as wel l

as i nconsi st enci es bet ween hi s r epor t ed pai n and hi s physi cal

movement s. Dur i ng each FCE, Or t ega al so ref used t o per f orm some

t est s. Revi ewi ng t he r esul t s of t he second FCE conduct ed by

Dr . Se n, Dr . Ocasi o i ni t i al l y recommended denyi ng Or t ega' s

benef i t s due t o hi s l ack of cooper at i on. Addi t i onal l y, Dr . Ri ver a

concl uded t hat Or t ega pr ovi ded "unr el i abl e" i nf or mat i on and

exagger at ed hi s psychi at r i c sympt oms. Ther ef or e, t he r ecord shows

t hat t he opi ni ons of sever al doct or s pr ovi de f ur t her suppor t f or

t he pl an admi ni st r at or ' s deci si on.

We have pr evi ousl y hel d t hat t he mere exi st ence of

cont r ar y medi cal evi dence does not r ender ar bi t r ar y and capr i ci ous

a pl an admi ni st r at or ' s deci si on t o cr edi t one opi ni on over anot her .

See Gannon, 360 F. 3d at 213. " I ndeed, when t he medi cal evi dence i s

shar pl y conf l i ct ed, t he def er ence due t o t he pl an admi ni st r at or ' s

det er mi nat i on may be especi al l y gr eat . " Leahy, 315 F. 3d at 19.

The pl an admi ni st r at or her e r evi ewed and consi der ed

Dr . Ramos' s f i ndi ngs, but i t ul t i mat el y concl uded t hat ot her

evi dence i n t he admi ni st r at i ve recor d - - i ncl udi ng Espi na' s r epor t

t hat Or t ega was uncooper at i ve and exaggerat i ng hi s sympt oms - - was

mor e per suasi ve. On t hat basi s, t he admi ni st r at or exer ci sed i t s

di scr et i on t o det er mi ne that Or t ega was no l onger el i gi bl e to

r ecei ve pl an benef i t s f or hi s al l eged cont i nui ng di sabi l i t y. See

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Medi na, 588 F. 3d at 46 ( " [ I ] n t he pr esence of conf l i ct i ng evi dence,

i t i s ent i r el y appr opr i at e f or a r evi ewi ng cour t t o uphol d t he

deci si on of t he ent i t y ent i t l ed t o exer ci se i t s di scr et i on. "

( quot i ng Gannon, 360 F. 3d at 216) ) . Such a concl usi on, suppor t ed

by subst ant i al evi dence, i s nei t her ar bi t r ar y, nor capr i ci ous, nor

an abuse of di scr et i on. See Leahy, 315 F. 3d at 18- 19 ( f i ndi ng t hat

wher e a pl an admi ni st r at or ' s det er mi nat i on t hat t he i nsured was not

f ul l y di sabl ed r est s on subst ant i al evi dence, i t cannot be sai d

t hat such a deci si on i s ar bi t r ar y and capr i ci ous) .

III. Conclusion

Gi ven t he cont ent s of t he admi ni st r at i ve recor d, t he pl an

admi ni st r at or ' s f i ndi ng t hat Or t ega was uncooper at i ve dur i ng hi s

f i nal FCE - - and t hus i nel i gi bl e f or cont i nui ng benef i t s - - was

r easonabl e and support ed by subst ant i al evi dence. The

admi ni st r at or ' s deci si on t o t er mi nat e Or t ega' s l ong- t er mdi sabi l i t y

benef i t s was, t her ef or e, nei t her ar bi t r ar y nor capr i ci ous. I n so

doi ng, t he admi ni st r at or al so di d not abuse i t s di scret i on t o

const r ue and i nt er pr et t he Pl an' s t er ms and det er mi ne whet her t her e

exi st ed gr ounds f or t er mi nat i on of Or t ega' s benef i t s. For t he

f or egoi ng r easons, we af f i r m t he j udgment of t he di st r i ct cour t .

AFFIRMED.

34

Candelaria v. Johnson & Johnson, 1st Cir. (2014)

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Transcript of Candelaria v. Johnson & Johnson, 1st Cir. (2014)