# United Stat es Court of Appeals For the First C ircuit

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 w hom L ourdes C. Hernández-Venegas and Schuster, Usera & Agulió LLP , were on brief for appellees.

September 25, 2003-2- 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 bene fits 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 participatedin Pfizer's Long TermDisability Benefits Plan, which prov ides disability benefits for participants who are "total l y disabled." Aparticipant 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 involve d in a ny other gainful occupation." After receiving plan benefits for two years, however, a participant will onlybe 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.1 The plan restricted benefits based on mental disability to a

maximum of two years. -3-

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 depre ssion. At the time, her condition satisfied the plan's first definition of "total disability."

After two years passed, however, Matías could only cont inue 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 wou ld res ult 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-4-

medical evaluation. On May14, 2001, Dr. Ocasio made a preliminary finding that Matías's reco rds did not indicate total disability. He noted that Matías did not appear to be following a regular treatment schedule with her physicians, a nd r ecommended a Functional Capacity Evaluation ("FCE").

Matías's FCE showed that she was able to work at a “sed entary physical demand level” during an eight-hour day. The tests suggested symptom exaggeration by Matías and "very poor effort or volunt ary submaximal effort which is not necessarily relatedto 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 term ination wi th MCS. As part of this appeal, she submittedadditional medical documents, including three undated doctors’ assessments of her physical capabilities during an eighthour workday. These “Residua l Functional Capacity Assessments” (“RFC Assessments”) varied in their conclusions as to the amount of activityMatías 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 two2 T he MRI revealed some abnormalities in Matías’s knee ,

including tears and degeneration. -5- to fo ur hours and stand for one to two hours. All found tha t Matías needed rest periods during the day.

MCS referred Matías’s full medical fil e, including the

ne w docu ments submitted on appeal, to Dr. Ocasio for evaluation, andon August 13, 2001, Dr. Ocasio once again recommended the termination of Matí as’ s benefits. He found that the additional mat erials 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 Matí as’s benefits, notifying her that she did not meet the definition of "totally disabled" under the plan. MCS conc luded that although Matías sufferedfrom several physical conditions that required treatment, she was able to work. MCS als o i nformed Matías of her right to appeal the decision by submitting any additional evidence she wished to have considered.

Matías req uested 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 andfirst appeal. Dr. Ocasio again revi ewed M atías’s medical-6-

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 s uit against Pfizer and MCS in the United States District Court for the District of Puerto Rico, claiming a violation of ERISA basedon the termination of her benefits. Matías claimed that she suffered from debilitating conditions and that MCS’s decisi on to terminate her benefits was arbitraryand 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 gr a nted the necessary discretionary authorityto MCS; and (2) MCS had not acted arbitrarily or capriciouslyin l i ght 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 bene fits 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 discretionaryauthority to determine eligibility for benefits.”3 Matías refers to a provision stating:

The Investment Committee shall administer the Plan and shall have the power and the duty, including discretionary authori ty, to take all actions and to make all decisions necessaryor proper to carry out the Plan, including, but not -7- Leahyv. Raytheon Co. , 315 F.3d 11, 15 ( 1st Cir. 2002) (citing Terryv. 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]h a ll have the power and the duty, including discretionaryauthority, to take all actions and to make all decisions nece ssary or proper to carry out the provisions of the Plan , includi ng, but not limited to, the following: * * * To interpret the Plan to determine whether a claimant is eligible for benefits, to dec ide 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 retainedth e au thority to reverse MCS’s decisions concerning the plan. As support, Matías points to language in the plan granting

an internal committ ee at Pfizer (the “Investment Committee”) authorityto administer the plan. 3 The district court rejectedlimited to, the following:

(a) To require any person to furnish such information as it mayrequest for the purpose of the proper administration of the Plan as a condition to receiving any benefit under the Plan; (b) To make andenf orce such rules and regulations and pre scribe the use of such forms as it shall dee m necessary or desirable for the efficient administration of the Plan; (c) To interpret the Plan, and to resolve a mbigui ties, inconsistencies and omissions, its interpretation and resolutio n to be finally conclusive and binding on all parties affected thereby; (d) To decide on ques tion s concerning the Plan and the eligibilityof 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 pe rson in accordance with the provisions of the Plan . . . . App. at 71. -8- 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 appe ar s to hold some administrative authority under the terms of the plan, MCS is the entitydesignated to administer claims under the plan, and to interpret the plan to determine a claimant’s eli gibility for benefits. MCS’s eligibilitydeterminations are “final, conclusive andbinding on all parties affected thereby.” Matías offers no basis to con clude that MCS lacked the discretionary authority to make the necessary judgment call s concerning her eligibility for-9-

benefi ts. 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 Twomeyv. Delta Airlines Pension Plan , 328 F. 3d 27, 31 (1st Cir. 2003). Where the

un derlyi ng decision by a plan administrator is subject to the arbitraryand capricious standard of review, our review involves an inquiry into “whether the aggregate evidence, viewed in the light most f avorab le to the non-moving party, could support a rational determinat ion t hat the plan administrator acted arbitrarily in denying the claim for benefits.” Id. (quoting Leahy , 315 F.3d at 18). Th e touc hstone 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 totallydisabled “is at odds with the gener ally re cognized requirement for sedentary jobs,” includin g the requirements set forth by the Social Security Administration. As t he district court noted, however, Matías w as required to satisfy the plan’s definition of tot al disa bility ( i.e. that she was completely unable to work in an occup ation for which she was, or might be, qualifi edbasedon her background). Cf. Pari-Fasano v. ITT HartfordLife & Accident Ins. Co. , 230 F.3d 415, 420 (1st Cir.-10-

2000) (“[A]ltho ugh a related Social Security benefits decision might be relevant t o a n insurer’s eligibility determination, it shouldnot 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 alleg es that MCS relied too heavily on the results of its own in ve stigation, and should have given more weight to her doctors’ di agnoses , including those that “flatly contradictedthe FCE.” But u nd er the applicable standard of review, the question is “not which side we b elieve is right, but whether the insurer had substantial evide nti ary 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.3d181, 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 c redit 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 nee d of medical treatment, sh e was not totally disabled within the meaning of the plan .-11-

Matías’s FCE generated evidence that she was capable of sedentary physical work. Tha t exam also showed signs of symptom exaggeration. Matías also submitted evidence, including three RFC Assess ments, from which an independent medical expert concluded that she could work for limitedperiods 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.