Of the District of New Hampshire, sitting by designation. *

United States Court of Appeals

For the First Circuit

No. 06-2087

JOSÉ MORALES-ALEJANDRO,

Plaintiff, Appellant,

v.

MEDICAL CARD SYSTEM, INC.,

Defendant, Appellee.

APPEAL FROM THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF PUERTO RICO

[Hon. Jay A. García-Gregory, U.S. District Judge]

Before

Torruella and Lynch, Circuit Judges,

and DiClerico, Jr., * District Judge. *

Héctor L. Claudio-Rosario on brief for appellant.

Lourdes C. Hernández-Venegas and Schuster & Aguiló, LLP on

brief for appellee.

May 16, 2007
Medical Card System, Inc., represents that Warner Lambert, 1

Inc., is now part of Pfizer Pharmaceuticals LLC.

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DICLERICO, District Judge. José Morales-Alejandro sought

reinstatement of long-term disability benefits, reimbursement of

his medical expenses, and payment of past long-term disability

benefits under the Employee Retirement Income Security Act of 1974

(“ERISA”), 29 U.S.C. § 1001, et seq. The district court considered

the parties’ cross motions for judgment on the administrative

record and granted Medical Card System, Inc.’s motion, concluding

that the decision to terminate Morales’s benefits was not arbitrary

or capricious. Morales appeals from that decision.

I.

Morales worked for seven years at Warner Lambert, Inc.,

and participated in the long-term disability plan (“Plan”) offered

there. In 1994, Morales filed a claim for long-term disability 1

benefits under the Plan, claiming disability due to bronchial

asthma and other ailments, which was approved by the Plan

administrator. As a condition for receiving benefits, Morales

filed an application for social security disability benefits, which

was approved. The Plan administrator required Morales to reimburse

the Plan for the social security benefits he had received. 

In 1997, Medical Card System, Inc. (“MCS”) became the

Plan administrator and approved the continuation of Morales’s
Other companies served as the Plan administrator prior to 2

July 1, 1997, when MCS assumed that function.

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benefits. At the end of 1999, the Social Security Administration 2

notified Morales that his social security benefits would continue,

subject to periodic review. MCS began a review of Morales’s

continued eligibility for benefits under the Plan in April of 2001.

As part of the review, MCS asked Morales to provide

updated medical information for the period from January of 2000 to

April of 2001. In response, Morales initially sent a list of his

hospitalizations from 1990 through early January of 2000, a list of

medications he was taking, and documentation of his move to Tortola

in the British Virgin Islands. MCS also required Morales to

undergo an independent examination by Dr. Rene Ramirez Ortiz, which

was conducted on May 4, 2001. Dr. Ramirez found that Morales had

mild persistent bronchial asthma with an appropriate level of

control and that he had been stable for the last few years. Dr.

Ramirez also noted that Morales had a bronchial cough during the

examination. Morales then sent MCS a note from his treating

physician, Dr. E. Castillo Volckers, dated May 21, 2001, stating

that Morales had been in his care for the past two years, had not

needed hospitalization during that time, but was not able to work.

An independent occupational medical consultant, Dr.

Ocasio, reviewed Morales’s entire file in June of 2001, noting

diagnoses of chronic obstructive pulmonary disease, high blood
Morales’s original counsel was not a member of the federal 3

bar, and therefore, could not participate in the case once it was

removed to federal court. 

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pressure, and diabetes. Dr. Ocasio concluded that Morales had a

mild and stable pulmonary condition and recommended that MCS

terminate Morales’s long-term disability benefits.

MCS notified Morales that his benefits would be

terminated as of June 30, 2001, and Morales appealed. With his

appeal, Morales resubmitted copies of the same information he had

provided in response to MCS’s request for his updated medical

records. An MCS disability specialist re-evaluated Morales’s file,

and based on the re-evaluation, MCS denied Morales’s appeal.

Morales filed suit against MCS in the Puerto Rico Court

of First Instance, San Juan, in April of 2005, alleging breach of

contract and seeking long-term disability benefits. MCS removed

the case to the United States District Court for the District of

Puerto Rico, asserting that Morales’s complaint raised claims

governed by ERISA. Once in federal court, MCS filed a motion on

August 12, 2005, requesting that the case be removed from the

standard track and decided on the administrative record. The court

granted the motion on September 7, 2005, setting a briefing

schedule.

On September 23, 2005, new counsel filed an appearance on

behalf of Morales. Counsel filed an opposition to MCS’s 3

previously-granted motion to have the case removed from the
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standard track, seeking discovery on an alleged conflict of

interest, and also moved for leave to file an amended complaint.

The district court denied the opposition and the motion for leave

to file an amended complaint. As required by the briefing

schedule, Morales moved for judgment on the administrative record.

He also filed a motion to set aside the court’s denial of his

motion for leave to file an amended complaint, and the court denied

this motion as untimely. MCS filed its motion for judgment on the

administrative record within the time allowed.

The case was referred to a magistrate judge for a report

and recommendation, which issued on January 11, 2006. The

magistrate judge recommended that the court grant MCS’s motion for

judgment and deny Morales’s motion. After Morales filed an

objection and MCS responded, the district court adopted the report

and recommendation on June 20, 2006. Judgment was entered in favor

of MCS, and this appeal followed.

II.

On appeal Morales contends that the district court abused

its discretion in denying his motion to amend his complaint and in

not allowing him to conduct discovery on the issue of MCS’s alleged

conflict of interest. Morales also contends that the district court

erred in concluding that MCS’s decision denying him benefits was not

arbitrary and capricious and that Morales was not prejudiced by
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MCS’s communications during the disability claim process. MCS

argues that the district court properly denied Morales’s motion for

leave to file an amended complaint and his request to conduct

discovery and did not err in granting MCS’s motion for judgment on

the administrative record.

A. Leave to Amend and Discovery

In his motion for leave to amend, Morales sought to add

allegations that procedural irregularities occurred during the

claims process and to add a “bad faith claim against the insurer.”

Morales’s request for discovery was included in his opposition to

MCS’s previously-granted motion to have the case removed from the

standard track. The district court denied the motion for leave to

amend and the request for discovery without a written opinion. On

appeal, Morales argues that decision was an abuse of discretion

because MCS had an inherent conflict of interest or bias toward

denying benefits based on its dual role as insurer and Plan

administrator.

A district court’s decision to deny leave to amend the

complaint is reviewed for an abuse of discretion. Universal Commc’n

Sys., Inc. v. Lycos, 478 F.3d 413, 418 (1st Cir. 2007). Under that

deferential standard, we uphold the district court’s decision “‘for

any reason apparent from the record.’” Id. (quoting Resolution

Trust Corp. v. Gold, 30 F.3d 251, 253 (1st Cir. 1994)). ERISA cases
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are generally decided on the administrative record without

discovery, and “some very good reason is needed to overcome the

presumption that the record on review is limited to the record

before the administrator.” Liston v. UNUM Corp. Officer Severance

Plan, 330 F.3d 19, 23 (1st Cir. 2003).

Morales’s conflict of interest theory is premised on a

mistaken assumption. As MCS points out, the Plan explains that it

is funded by contributions from participating companies, and in this

case it is Warner Lambert. The contributions are held in a trust

fund for the benefit of Plan participants and beneficiaries. MCS

administers claims under the Plan but does not insure the Plan.

Successful claims are paid from the trust fund and not by MCS.

Therefore, Morales’s “inherent” conflict of interest theory is not

supported by the record, and he showed no other reason to support

his request for discovery. The district court did not abuse its

discretion in denying his motion for leave to amend and his request

for discovery.

B. Decision to Terminate Benefits 

The district court decided this case based on the

parties’ motions for judgment on the administrative record. Our

review is de novo. See Bard v. Boston Shipping Ass’n, 471 F.3d

229, 235 (1st Cir. 2006). 
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When, as here, an ERISA plan gives the plan administrator

discretionary authority to interpret the terms of the plan and to

determine a claimant’s eligibility for benefits, we will uphold the

decision unless it is arbitrary, capricious, or an abuse of

discretion. Tsoulas v. Liberty Life Assurance Co. of Boston, 454

F.3d 69, 76 (1st Cir. 2006). Under that standard, the decision

“must be upheld if there is any reasonable basis for it.” Madera

v. Marsh USA, Inc., 426 F.3d 56, 64 (1st Cir. 2005). Stated in

different terms, we will uphold an administrator’s decision “if the

decision was reasoned and supported by substantial evidence,”

meaning that the evidence “is reasonably sufficient to support a

conclusion and contrary evidence does not make the decision

unreasonable.” See Denmark v. Liberty Life Assurance Co. of Boston,

--- F.3d ---, 2007 WL 914673, at *15 (1st Cir. Mar. 28, 2007). 

MCS concluded that Morales had a mild pneumological

condition that had become stable with treatment so that he no longer

qualified for disability benefits. That decision was based on Dr.

Ramirez’s opinion, following his examination, and on consideration

of all of the records in Morales’s file. Morales argues that MCS

used the wrong definition of disability, which was less favorable

to him. Morales contends that the definition of disability in the

Summary Plan Description (“SPD”), quoted by MCS in its letter

terminating his benefits, is narrower than the definition of

disability in the Plan. Morales further contends that MCS’s use of
The Plan defines disability as follows: 4

Total Disability or Totally Disabled: The complete

inability of an Employee to perform substantially all of

the material duties of his or her regular occupation as

it is generally performed in the national economy, or

perform another occupation for which the Employee is

qualified and can earn at least 75% of pre-disability

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the SPD definition imposed a more onerous burden of proving

disability than the Plan demanded.

ERISA imposes an important requirement on plan

administrators and insurers to communicate accurately with plan

participants and beneficiaries. See Bard, 471 F.3d at 244-45. Part

of the communication requirement is that the SPD provide certain

information “written in a manner calculated to be understood by the

average plan participant, and shall be sufficiently accurate and

comprehensive to reasonably apprise such participants and

beneficiaries of their rights and obligations under the plan.” 29

U.S.C. § 1022(a). Section 1022(b) specifies the information to be

included in the summary. When the terms, language, or provisions

of the SPD conflict with the plan, the language that the claimant

reasonably relied on in making and proving his claim will govern the

claim process. Bard, 471 F.3d at 245. The burden is on the

claimant to show reasonable reliance and resulting prejudice. Id.

Although he asserts that the Plan’s definition of

disability is more favorable to him than the definition contained

in the SPD, Morales does not show that he would have qualified for

benefits under the Plan’s definition. As such, Morales has not 4
Compensation. The Covered Employee cannot engage in any

other employment except as provided under the

rehabilitation program described in Article 14.

The SPD provides in pertinent part:

Total Disability . . .

 After you have received the benefits of the plan for

two years, you will be considered completely disabled if

you cannot work in occupations or employment for which

you are qualified or could be qualified in accordance to

your academic preparation, training or experience.

To the extent Morales also argues that he was misled by MCS’s 5

use of the definition in the SPD, that theory is not well developed

and would also fail due to a lack of evidence that he was

prejudiced.

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shown that he reasonably relied on the Plan definition in making his

claim for benefits and that the difference in definitions resulted

in MCS’s denying his claim. Therefore, as the district court

decided, Morales has not sustained his burden of proof on this

issue.5

Morales also contends that MCS was required to give the

disability ruling by the Social Security Administration controlling

weight because MCS required him to apply for social security

benefits and then to reimburse the Plan for the amount he received

from social security. Contrary to Morales’s argument, however,

“benefits eligibility determinations by the Social Security

Administration are not binding on disability insurers.” Pari-Fasano

v. ITT Hartford Life & Accident Ins. Co., 230 F.3d 415, 420 (1st

Cir. 2000)). Morales offers no persuasive authority to support his
Morales relies on Calvert v. Firstar Fin., Inc., 409 F.3d 6

286, 293-95 (6th Cir. 2005), which held that a social security

ruling is one factor for the plan administrator to consider in

making its disability determination. Morales has not shown that

MCS refused to consider the social security ruling in making its

own independent determination. See Denmark, 2007 WL 914673, at *20

(discussing Calvert).

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theory that as a result of MCS’s reimbursement requirement the

social security ruling must be given controlling weight in MCS’s

decision-making process.6

Alternatively, Morales argues that the social security

ruling governs because the definition of disability under the Social

Security Act is more restrictive than the Plan’s definition. To

qualify for disability benefits under a plan, a claimant must

satisfy the plan’s definition of disability, not the definition of

disability under the Social Security Act. Matias-Correa v. Pfizer,

Inc., 345 F.3d 7, 12 (1st Cir. 2003). For that reason, a related

social security ruling “should not be given controlling weight

except perhaps in the rare case in which the [social security]

statutory criteria are identical to the criteria set forth in the

insurance plan.” Pari-Fasano, 230 F.3d at 420. 

Aiming at the rare case, Morales asserts that the

definition of disability under the Social Security Act is narrower

than the Plan’s definition so that the social security ruling should

be given controlling weight here. He fails to cite the social

security definitions on which he relies, however, or provide any

analysis to support his theory. As MCS points out, another claimant
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was unable to show that a social security ruling in her favor was

entitled to controlling weight for purposes of a disability

determination by MCS under the same Plan. See Matias-Correa, 345

F.3d at 12. Therefore, Morales has not shown that his is the rare

case where a related social security ruling should be given

controlling weight. 

Morales more generally attacks MCS’s decision to

terminate his benefits on the ground that the record lacks

substantial evidence to support it. He asserts that the record does

not include evidence that his medical condition changed or that he

is now able to work. He faults MCS for failing to have him undergo

a functional capacity evaluation and for failing to have him

assessed by a vocational rehabilitation specialist. He also cites

the lack of a labor market survey to show what work was available

for him to do.

Morales’s arguments show that he fails to understand that

it is his responsibility to prove his claim. A claimant seeking

disability benefits bears the burden of providing evidence that he

is disabled within the plan’s definition. See Wright v. R.R.

Donnelley & Sons Co. Group Benefits, 402 F.3d 67, 77 (1st Cir.

2005). In addition, a plan administrator is not obligated to accept

or even to give particular weight to the opinion of a claimant’s

treating physician. Black & Decker Disability Plan v. Nord, 538
In fact, even in the context of social security disability 7

claims, where deference is ordinarily accorded to the opinions of

treating physicians, see 20 C.F.R. § 404.1527(d)(2), no deference

is given to a physician’s opinion that a claimant is disabled or

unable to work because that is not a medical opinion, see id. at §

404.1527(e)(1); Ellis v. Barnhart, 392 F.3d 988, 994 (8th Cir.

2005).

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U.S. 822, 831 (2003). Therefore, Morales bore the burden of showing

that he continued to be disabled, as defined in the Plan.

MCS asked Morales to provide updated medical records to

support his claim. The records he provided demonstrated that his

hospitalizations stopped in early January of 2000 and that he had

not needed hospital care since that time. Morales’s treating

physician confirmed that fact. Morales provided no records of any

medical care during the period in question other than a list of

medications he was taking. Dr. Volcker’s opinion that Morales was

unable to work was not entitled to any weight in the context in

which it was offered. The records Morales provided, along with the 7

opinions of Dr. Ramirez and Dr. Ocasio, showed that Morales’s

pneumological condition was stable with treatment and supported

MCS’s conclusion that he was no longer disabled. Therefore, the

district court correctly decided that MCS’s termination of Morales’s

benefits was not arbitrary or capricious.

III.

For the foregoing reasons, the district court did not

abuse its discretion in denying Morales’s motion for leave to amend
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his complaint and his request to conduct discovery. In addition,

MCS’s decision to terminate Morales’s disability benefits was not

arbitrary or capricious. Therefore, we uphold the district court’s

decision.

Affirmed.