Opinion ID: 202743
Heading Depth: 2
Heading Rank: 2

Heading: Decision to Terminate Benefits

Text: 18 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). 19 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, 481 F.3d 16, 33 (1st Cir. 2007). 20 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 SPD definition imposed a more onerous burden of proving disability than the Plan demanded. 21 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. 22 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. 4 As such, Morales has not 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 23 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 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 24 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. 25 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 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. 26 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. 27 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 U.S. 822, 831, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). Therefore, Morales bore the burden of showing that he continued to be disabled, as defined in the Plan. 28 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. 7 The records Morales provided, along with the 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.