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
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HOWARD, Circuit Judge. Plaintiff-appellant Nancy MatíasCorrea 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.
1The plan restricted benefits based on mental disability to a

maximum of two years. 

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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
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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 eighthour 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
2The MRI revealed some abnormalities in Matías’s knee,

including tears and degeneration.

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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
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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.”
3Matías 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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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
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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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
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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.