Opinion ID: 2678508
Heading Depth: 3
Heading Rank: 2

Heading: Ortega's Claim Under the Plan

Text: As an electrician for Ortho Biologics LLC, Ortega held a mostly active job that required bending, walking, climbing, [and] working [in a] standing position for long period[s] of time, and which required him to pull, push, lift/carry and squat on a routine basis. Ortega alleges that since 2002, he has been unable to work due to constant pain caused by vertebral herniations, degenerative scoliosis, osteoarthritis, and radiculopathies. He also claims to suffer from anxiety, panic disorder, and depression. As a result of these conditions, Ortega went on non-occupational disability leave, and he began receiving short-term disability benefits on October 28, 2002. Subsequently, on June 3, 2003, Ortega submitted his first claim for long-term disability benefits, in which he asserted that he was unable to bend or walk, experienced consistent pain in his legs and back, and suffered from anxiety, panic attacks, and depression. Shortly thereafter, MCS received two Attending Physician Statements in support of Ortega's claim. The first of these statements addressed Ortega's mental and emotional condition, concluding that Ortega suffered from panic disorder as well as major depression. The second statement, regarding Ortega's -5- physical ailments, specified that he suffered from radiculopathies, herniation of lumbosacral discs, degenerative scoliosis, and osteoarthritis. Ortega's claim for long-term disability benefits for his physical condition was approved on July 23, 2003, but Ortega was notified that such benefits would apply retroactively beginning from June 24, 2003. Ortega's claim for benefits due to his mentalhealth symptoms, however, was denied. In its subsequent confirmation of the approval of Ortega's physical claim, MCS advised Ortega that he was required to undergo regular treatment with a specialist and that his case would be reevaluated periodically by MCS's Medical Committee to determine his continued eligibility for long-term disability benefits. On October 20, 2003, MCS requested that Ortega provide a copy of the medical records held by his attending physicians at the time in order to determine his continued eligibility for long-term disability benefits. Thereafter, on October 30, 2003, Ortega participated in a functional capacity evaluation (FCE) conducted by Rafael E. Seín, M.D. (Dr. Seín), a physiatrist, or rehabilitation physician. Dr. Seín reported that Ortega: demonstrated a very restricted -- or sub-minimal -- effort during the weighted and non-weighted activities, with a more mental involvement that aggravates his physical condition; frequently shifted weight on -6- either leg despite his major pain symptoms being related to his right leg only; demonstrated inconsistency on a hand-grip test; and refused to perform some activities due to fear of being injured. On that basis, Dr. Seín recommended an independent psychiatrist evaluation. He concluded that Ortega had the physical capacity for sedentary work, but with restrictions on prolonged standing, sitting, and walking. In contrast, in progress notes dated November 4, 2003, Ortega's attending physician -- Oscar E. Ramos Román, M.D. (Dr. Ramos) -- stated that Ortega was permanently disabled from work, noting that he still suffered from severe neck and back pain, scoliosis, anxiety, and depression. On November 25, 2003, upon reviewing Dr. Ramos's progress notes and the results of the FCE, MCS's independent medical consultant -- José Ocasio, M.D. (Dr. Ocasio) -- recommended extending Ortega's benefits, but further recommended that Ortega be reevaluated six months later. On April 6, 2004, Ortega underwent a second FCE, again conducted by Dr. Seín. Following the examination, Dr. Seín's report stated that Ortega demonstrated very inconsistent efforts throughout the FCE and that he refused to attempt several activities, both weighted and non-weighted, which he had performed in the prior FCE. Dr. Seín again concluded that Ortega had the functional capacity for sedentary activities, albeit with restrictions. -7- On April 28, 2004, after evaluating Dr. Seín's report, Dr. Ocasio recommended denying Ortega's long-term disability benefits due to his lack of cooperation during the second FCE. However, Dr. Ocasio later reconsidered, and he ultimately recommended approval of the benefits. As before, Dr. Ocasio further recommended that Ortega undergo reevaluation in six months. On August 19, 2004, MCS informed Ortega that, because Dr. Ramos's progress notes continued to mention Ortega's mental health, MCS was reevaluating the denial of his long-term disability benefits regarding his mental and emotional state. Luis E. Cánepa, M.D. (Dr. Cánepa), reviewed a copy of the progress notes regarding Ortega's mental health and concluded that Ortega's emotional conditions seemed moderate in severity. Dr. Cánepa further recommended that Arlene Rivera-Mass, M.D. (Dr. Rivera), a psychiatrist, perform an independent medical evaluation of Ortega. Following this psychiatric medical evaluation conducted on October 13, 2004, Dr. Rivera concluded that, while Ortega presented symptoms compatible with panic and mood disorder, it seem[ed] that there was a frank exaggeration of symptoms. For example, Dr. Rivera noted that Ortega claimed extremely poor memory but did not present in the interview [with] such difficulty. Dr. Rivera opined that the information he gave during the interview is unreliable, and that as a result, further -8- investigation should occur in order to correctly diagnose Ortega's mental and emotional symptoms. After reviewing Dr. Rivera's conclusions, Dr. Cánepa recommended denying Ortega long-term disability benefits based on his mental state. C. The FCE Conducted by Javier Espina on November 16, 2004 On November 16, 2004, Ortega underwent a third FCE, which was conducted by Javier Espina (Espina), a physical therapist. Espina said that Ortega would only be asked to perform activities he felt capable of completing; Ortega could stop any test that caused him pain, if he so desired. Espina further instructed Ortega to exert his best efforts in attempting each activity. Following the FCE, Espina concluded that Ortega's symptomatic reports and behavior are out of proportion to the objective physical findings and the identified pathology. Specifically, Espina reported that Ortega: did not complete all test activities; declined all lifting, carrying, pushing, pulling and climbing activities, stating that he did not want to risk further injury; and demonstrated a consistent submaximal effort throughout this evaluation. For example, Espina's report observed that Ortega declined the (Right Leg) Sitting Leg Raising test, stating that he couldn't flex his Right Knee, although the testing center's video clearly shows that Mr. Ortega [was] able to Sit and Flex his Right Knee while seated in the waiting room. -9- Espina further determined that Ortega demonstrated a regional, non-specific testing pattern that is not consistent with an organic pain syndrome. Ortega's scores on testing protocols indicat[ed] that there is a non-organic component to his pain, medical impairment and disability. During this FCE, Ortega passed only three out of twenty-one validity criteria, which are used to objectively determine whether a patient is honestly trying his or her best to complete the various physical tasks required for the evaluation. According to Espina, this fourteen-percent pass rate suggests very poor effort or voluntary sub maximal effort, which is not necessarily related to pain, impairment or disability.4 4 Espina's report notes that a person's Validity Profile is comprised of a cohort of individual tests that collectively help determine whether or not the patient is exerting their best effort during all of the FCE tests. Failing the test indicates that the patient has not exerted their best effort. Because the patient is not asked to perform tasks for which they do not have the physical ability and the test data should reveal if the patient does not have such ability, then the only reason for not passing the overall Validity Profile is that the patient was not motivated to cooperate with the evaluation process and exert their best effort. According to the report, failing the Overall Validity Profile is viewed as a voluntary act of non-compliance with the testing process and the professionals who requested the test. With respect to the number of validity criteria passed, a rate of 90-100% indicates Excellent Effort, 80-89% indicates Good Effort, 70-79% indicates Fair Effort, 60-69% indicates Poor Effort, and less than 60% indicates Very Poor Effort. Ortega passed only 14% of the validity criteria, leading Espina to conclude that his performance was Invalid and demonstrated Very Poor Effort. -10- Espina observed that Ortega's movement patterns improved significantly by distraction when compared to the ability he demonstrated during direct observation. Such a finding suggests that Ortega was attempting to control the test results to demonstrate more pain and disability than [were] actually present. As one example, in evaluating Ortega's gait, Espina noted that Ortega's movements while walking exhibited a poor correlation with the pain rating and that his behavior is inappropriate. In concluding his detailed analysis, Espina reported that Ortega's behavior and physical performance were not consistent with his stated symptoms and alleged disability. Instead, Espina concluded that Ortega was, in fact, exaggerating his symptoms and disabilities.5 D. The Termination of Ortega's Benefits On November 22, 2004, after reviewing Espina's report and Dr. Ramos's updated progress notes, Dr. Ocasio recommended denying Ortega long-term disability benefits due to his lack of cooperation during the third FCE. Accordingly, MCS notified Ortega that, pursuant to the Plan's terms, Ortega's lack of cooperation in the evaluation process justified the termination of his long-term disability benefits. 5 The report states that The Movement Patterns and Behavior Are Not Consistent with the Symptoms and Disability, and concludes that True Symptom/Disability Exaggeration Exists. -11- On January 12, 2005, Ortega appealed that decision. He attached a letter dated December 10, 2004, in which Dr. Ramos concluded that, in his professional opinion, Ortega was totally and permanently disabled to work. On January 19, 2005, after reviewing Ortega's records -- including the updated progress notes from all of Ortega's attending physicians -- Dr. Ocasio nevertheless recommended the denial of Ortega's appeal because Ortega presented no new evidence that would support a different recommendation. Ortega requested a second appeal of his claim on February 24, 2005. He attached Dr. Ramos's signed medical certificate, which stated that Ortega's physical condition was progressive, he still suffered from severe back pain, and he was incapable of performing the tests requested by MCS. On March 20, 2005, after reviewing Ortega's second appeal, the Johnson & Johnson Disability Review Committee upheld the decision to terminate his long-term disability benefits for failing to cooperate with the evaluations of his continuing disability. Additionally, in its review of Ortega's record, the Disability Review Committee found no circumstances justifying or explaining Ortega's lack of cooperation or his exaggeration of symptoms. Lastly, the committee found that Ortega himself failed to provide any explanation for his lack of cooperation/compliance in completing the tests that were included in the FCE. -12- E. Procedural History Before the district court, Ortega argued that the Appellees arbitrarily and capriciously denied his benefits due under ERISA, and he requested a judgment ordering the reinstatement of those benefits as well as the retroactive payment of past benefits.6 After granting Appellees' motion to proceed with the matter as an administrative appeal, the district court granted Appellees' motion for judgment on the administrative record and dismissed Ortega's claim with prejudice on March 26, 2013. In so doing, the district court held that the record provided the plan administrator ample basis for finding that Ortega did not cooperate fully during the FCE held on November 20, 2004, and thus Appellees did not act arbitrarily and capriciously in terminating Ortega's benefits. This appeal followed.