Court Opinion

ID: 2678508
Source: CourtListenerOpinion
Date Created: 2014-06-16 19:00:43.69534+00
Date Added: 2024-06-11T08:45:52.830438
License: Public Domain

United States Court of Appeals
                      For the First Circuit

No. 13-1564

                    ROLANDO ORTEGA-CANDELARIA,

                       Plaintiff, Appellant,

                                v.

           JOHNSON & JOHNSON; MEDICAL CARD SYSTEM, INC.,

                      Defendants, Appellees.

           APPEAL FROM THE UNITED STATES DISTRICT COURT
                  FOR THE DISTRICT OF PUERTO RICO

          [Hon. José Antonio Fusté, U.S. District Judge]

                              Before

                 Torruella, Baldock,* and Kayatta,
                          Circuit Judges.

     Pedro J. Landrau-López, for appellant.
     Lourdes C. Hernández-Venegas, with whom Elizabeth Pérez-
Lleras, Shiara L. Diloné-Fernández and Schuster Aguiló LLP, were on
brief for appellees.

                           June 16, 2014

*
    Of the Tenth Circuit, sitting by designation.
             TORRUELLA, Circuit Judge.       Plaintiff-Appellant Rolando

Ortega-Candelaria ("Ortega") appeals the district court's dismissal

of his claims under the Employee Retirement Income Security Act

("ERISA"), 29 U.S.C. §§ 1001-1461.           Before the district court,

Ortega sought judicial review of the decision to terminate payment

of disability benefits to him under Johnson & Johnson's Long-Term

Disability    Plan   (the   "Plan").       Ortega   requested    a   judgment

restoring his terminated benefits and ordering payment of past

benefits.       The district court dismissed Ortega's claims with

prejudice.

             On appeal, Ortega argues that Johnson & Johnson and

Medical Card System, Inc. ("MCS") (collectively, the "Appellees")

arbitrarily and capriciously terminated his disability benefits.

Ortega   contends    that   the   Appellees      erroneously    credited   an

examination by a physical therapist over the opinion of his

treating    physician.      Given    the   substantial    record     evidence

supporting the Appellees' determination, we find that the decision

to terminate Ortega's benefits did not constitute an abuse of

discretion and was neither arbitrary nor capricious.            We affirm.

                             I.     Background

A.   The Plan

             Johnson & Johnson sponsors the Plan to provide long-term

disability benefits for its employees and the employees of its

affiliated companies.       Ortega received coverage under the Plan

                                     -2-
while working in Puerto Rico as an electrician for Ortho Biologics

LLC, a subsidiary of Johnson & Johnson.

             In order to be eligible for plan benefits, a participant

must be considered "totally disabled."           During the first twelve

months of an injury or sickness, a plan participant must be unable

to perform the essential functions of his or her "regular job" in

order to qualify as "totally disabled."         If the injury or sickness

lasts longer than twelve months, the participant must remain

completely unable "to do any job" -- "with or without reasonable

accommodation,"     and   "for   which    the   Participant   is   (or   may

reasonably become) qualified by training, education, or experience"

-- in order to continue to be classified as "totally disabled."

             Pursuant to the Plan, the plan administrator maintains

"the right to conduct evaluations of a Participant's medical status

and eligibility for benefits" at any time while a claim is pending

or the participant is receiving benefits.1        The Plan further grants

the   plan   administrator   the   sole   discretion   "to    construe   and

interpret" the Plan's terms and the sole discretion to determine

1
   As defined in the Plan, and as used herein, the term "plan
administrator" encompasses both the Johnson & Johnson Pension
Committee ("Pension Committee") and MCS, the claims services
organization   retained    by  Johnson    &  Johnson   to   provide
administrative services related to the Plan. "In the event of a
denial or limitation of benefits," a participant may appeal to MCS.
If MCS upholds the original denial of benefits, the participant may
appeal a second time to the Pension Committee. A participant may
commence a lawsuit only after a final decision has been rendered on
this second appeal.

                                    -3-
whether there exist grounds for termination of a participant's

benefits.2     Under the Plan, such grounds include a claimant's

failure to cooperate with respect to any procedure or evaluation in

connection with the Plan.3

             A participant making a claim for benefits under the Plan

must provide "all information necessary to evaluate his or her

medical   condition    and   functional   capacity."   At   the   plan

administrator's discretion, "the evaluation may include medical

examination(s) by a Plan Provider."         Further, "[o]ne or more

Independent Medical Examination(s) (IME) and Functional Capacity

2
   In relevant part, Article VII of the Plan states that the plan
administrator "has the sole authority to . . . [e]xercise its
discretion to determine eligibility for benefits, to construe and
interpret the provisions of the Plan and to render conclusive and
binding decisions and determinations based thereon."
3
    In the section titled "Evaluation of Participant's Medical
Status," the Plan states that a participant making a claim is
required to "cooperate . . . in the evaluation of the Participant's
medical status."    "Failure or refusal by the Participant to
cooperate in the medical evaluation . . . shall constitute grounds
for terminating benefits under the Plan."

   In a section titled "Exclusions from Payment of Benefits," the
Plan further states, in relevant part, that:

     Notwithstanding any other provision of this Plan, in no
     event shall a Participant be considered Totally Disabled
     or remain Totally Disabled, and no benefit shall be
     payable under this Plan . . . on or after the date a
     Participant . . . fails or refuses to cooperate with
     respect to the evaluation of his/her Total Disability or
     continuing Total Disability or with respect to any
     procedure, evaluation, investigation or audit in
     connection with this Plan . . . .

                                  -4-
Examination(s) (FCE) may be required at any time during the claim

evaluation process."

B.   Ortega's Claim Under the Plan

             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 mental-

health      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 sub-

maximal 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.

                               II.     Analysis

             We generally review the denial of benefits under an ERISA

plan de novo.     See Firestone Tire & Rubber Co. v. Bruch, 489 U.S.

101, 115 (1989); Gross v. Sun Life Assurance Co. of Can., 734 F.3d

1, 11 (1st Cir. 2013) (stating that "[t]he default standard for

reviewing [ERISA] benefits decisions . . . is de novo"). However,

where the plan grants the plan administrator or another fiduciary

the discretionary authority to construe the terms of the plan or to

6
   Ortega also sought an award of costs and attorney's fees, plus
any other available damages and remedies.

                                     -13-
determine a participant's eligibility for benefits, as is the case

here, we apply a deferential standard of review, upholding the

administrator's decision "unless it is 'arbitrary, capricious, or

an abuse of discretion.'" See Cusson v. Liberty Life Assurance Co.

of Bos., 592 F.3d 215, 224 (1st Cir. 2010) (quoting Gannon v.

Metro. Life Ins. Co., 360 F.3d 211, 213 (1st Cir. 2004).

          This deferential standard of review, however, is not

entirely without teeth -- it requires that a determination by a

plan administrator "must be 'reasoned and supported by substantial

evidence.'" Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack

Anesthesia Assocs. Long Term Disability Plan, 705 F.3d 58, 62 (1st

Cir. 2013) (quoting D & H Therapy Assocs., LLC v. Bos. Mut. Life

Ins. Co., 640 F.3d 27, 35 (1st Cir. 2011)).        "In short," such a

determination "must be reasonable."         Id. (citing Conkright v.

Frommert, 559 U.S. 506, 521-22 (2010)).

          Specifically, "the question is 'not which side we believe

is   right,   but   whether   the    [administrator]   had   substantial

evidentiary grounds for a reasonable decision in its favor.'"

Matías-Correa v. Pfizer, Inc., 345 F.3d 7, 12 (1st Cir. 2003)

(quoting Brigham v. Sun Life of Can., 317 F.3d 72, 85 (1st Cir.

2003)).   Evidence is deemed substantial "when it is reasonably

sufficient to support a conclusion."         Cusson, 592 F.3d at 230

(quoting Wright v. R.R. Donnelley & Sons Co. Grp. Benefits Plan,

402 F.3d 67, 74 (1st Cir. 2005)). Moreover, so long as substantial

                                    -14-
evidence supports the plan administrator's decision, the decision

is not rendered unreasonable by the mere existence of evidence to

the contrary.    Id.

           Although a plan administrator "may not arbitrarily refuse

to credit a claimant's reliable evidence, including the opinions of

a   treating   physician,"    we   do   not   require   administrators   to

automatically grant "special weight" to the opinion of a claimant's

chosen provider.       Black & Decker Disability Plan v. Nord, 538 U.S.

822, 834 (2003); see also Medina v. Metro. Life Ins. Co., 588 F.3d

41, 46 (1st Cir. 2009) ("A plan administrator is not obligated to

accept or even to give particular weight to the opinion of a

claimant's treating physician." (quoting Morales–Alejandro v. Med.

Card Sys., Inc., 486 F.3d 693, 700 (1st Cir. 2007))).          Similarly,

courts may not impose "a discrete burden of explanation" on plan

administrators "when they credit reliable evidence that conflicts

with a treating physician's evaluation."         Black & Decker, 538 U.S.

at 834.   "Consequently, 'in the presence of conflicting evidence,

it is entirely appropriate for a reviewing court to uphold the

decision of the entity entitled to exercise its discretion.'"

Medina, 588 F.3d at 46 (quoting Gannon, 360 F.3d at 216).

           On appeal, Ortega raises several arguments in support of

his position that the district court erred in granting judgment on

the administrative record in favor of the Appellees. Specifically,

Ortega argues that the district court erred in concluding that he

                                    -15-
did not cooperate during the third and final FCE.                He further

asserts that because Espina is not a medical doctor, the plan

administrator abused its discretion in crediting Espina's opinion

over that of Dr. Ramos.       As explained below, we find that these

arguments are unpersuasive and do not require reversal.

A.   Whether Ortega Did Not Cooperate with a Required Evaluation

            Ortega   relies   heavily    on    his   assertion      that   the

administrative record lacks evidence that he was uncooperative

during the third and final FCE, which was conducted on November 16,

2004.    A review of the record, however, reveals significant

evidence in support of the plan administrator's decision, as

detailed in the foregoing summary of the factual background and as

further explained below.

            Ortega also argues that the district court erred in

finding that because he "had successfully completed evaluations in

the past without being found uncooperative," the court could be

"confident that he understood how to try the tasks requested of

him" during his final FCE, "even if he could not complete every

one."   Asserting that such a finding was based on a "selective

review" of the record, Ortega puts forth two explanations for his

lack of cooperation during the third FCE. First, he argues that he

did not complete certain evaluation tasks because he was simply

following   the   instructions   of     both   Espina   and   his    treating

physician, Dr. Ramos, to avoid actions that could cause him further

                                  -16-
injury.7   Second, Ortega notes that there was evidence on the

record showing that he was cooperative during earlier FCEs.       He

further argues that his medical condition is degenerative, and that

it is therefore only natural that he would not be able to complete

subsequent tests as well as he had completed prior evaluations.

           These arguments misunderstand both the district court's

reasoning as well as the relevant standard.      Immediately after

finding that Ortega knew how to complete the FCE tasks, the

district court further explained: "[i]n any event, the point is not

whether every observer would have agreed Ortega-Candelaria was

uncooperative, but whether the plan administrator had sufficient

evidence to conclude that he was uncooperative."     Indeed, it is

certainly plausible that Ortega was suffering from a degenerative

condition that rendered him unable, during the third FCE, to

perform physical tasks that he had previously been able to perform

in prior FCEs.   And it is further plausible that Ortega's refusal

to perform certain tasks was not because he was feigning his

injuries or exaggerating his symptoms, but was because he was

either experiencing severe pain or following his physician's orders

not to perform movements that were likely to further injure him.

7
  According to Ortega, Dr. Ramos informed him that he should avoid
certain activities, including: "sitting-standing," bending,
walking, pulling, lifting, carrying, and operating foot-pedals.
Presumably, Ortega reasons that this medical advice constituted an
absolute prohibition, such that he should avoid even attempting
such activities during medical or functional evaluations.

                               -17-
             Yet the operative standard is not whether Ortega has put

forth a plausible narrative, or whether we are more persuaded by

Ortega's account of the facts than by Appellees' version.                     See

Matías-Correa, 345 F.3d at 12 ("[T]he question is 'not which side

we believe is right . . . .'" (quoting Brigham, 317 F.3d at 85)).

Rather, we ask whether the plan administrator had evidence that is

"reasonably sufficient" to support its determination.               See Cusson,

592 F.3d at 230 (quoting Wright, 402 F.3d at 74).

             A review of the administrative record reveals that such

evidence     was    present   here.    Ortega's      assertion    that   he   was

physically unable to complete some of the tests does not vitiate

Espina's findings that Ortega failed to cooperate by putting forth

his best efforts to attempt the tasks requested during the third

FCE.    While Espina did state that Ortega would not be asked to

complete any test he felt unable to perform and that he could stop

any task if pain occurred, Espina further instructed Ortega to

exert his best effort on each test absent any increased pain.

             Despite this instruction, the results of Ortega's final

FCE "suggest[ed] very poor effort or voluntary sub maximal effort,

which   is    not     necessarily     related   to    pain,      impairment    or

disability."          Espina's   results     suggested    that     Ortega     was

"attempting to control the test results to demonstrate more pain

and disability" than he was actually experiencing.               Ortega refused

to perform many of the tasks.         His movements while walking did not

                                      -18-
correspond with his pain reports.        He failed eighty-six percent of

the validity criteria, which are used to determine whether a

patient is honestly using his or her best efforts to perform the

required physical tests.

             Video footage further supports the conclusion that Ortega

was not cooperative; the video shows Ortega flexing his right knee

in the waiting room prior to his final FCE -- an act which he later

refused to perform during the FCE itself.               Espina's evaluation

ultimately     determined    that    Ortega's      behavior   and   physical

performance were not consistent with his reported symptoms and

alleged   disability;      Espina    thus   concluded     that   Ortega   was

exaggerating his symptoms.

             Moreover, Espina's report was not the first indication in

the record that Ortega was exaggerating his symptoms.               Dr. Seín

reported that Ortega demonstrated a "very restricted" or "sub-

minimal" effort during his first FCE.              Additionally, Dr. Seín

observed that Ortega frequently shifted his weight on either leg

despite complaining of major pain symptoms with respect to only his

right   leg.      Ortega    also    demonstrated    inconsistency    in   his

performance of a hand-grip test and refused to perform some tasks.

             During the second FCE conducted by Dr. Seín, Ortega

demonstrated very inconsistent efforts and refused to perform

several tests, including some that he had previously completed in

the first FCE.      On that basis, Dr. Ocasio initially recommended

                                     -19-
denying Ortega's benefits due to this lack of cooperation.

Furthermore,    following   a   psychiatric    evaluation,      Dr.   Rivera

determined that Ortega gave "unreliable" information and displayed

"exaggeration of symptoms" during his examination.

             With the foregoing facts in mind, we conclude that the

record   contains   evidence    reasonably    sufficient   to    support   a

determination that Ortega was uncooperative during his evaluation.

See Cusson, 592 F.3d at 230 (deeming evidence substantial "when it

is reasonably sufficient to support a conclusion" (quoting Wright,

402 F.3d at 74)).

             The Plan's terms require that Ortega cooperate during

evaluations of his disability status; without such cooperation, the

plan administrator retains the right to reduce or terminate his

benefits.8    Therefore, because the evidence on the administrative

record permits a reasonable finding that Ortega was uncooperative

during his third FCE, the Appellees' decision to terminate Ortega's

benefits cannot properly be deemed arbitrary and capricious or an

abuse of discretion.        See Morales-Alejandro, 486 F.3d at 700

8
   "The Plan Administrator . . . reserves the right to reduce or
terminate benefits at any time if it is determined that a
Participant no longer qualifies for benefits under the terms,
conditions, and definitions of the Plan.     Without limiting the
foregoing, failure or refusal by a Participant to . . . cooperate
with any other procedures, evaluation, investigation or audit . . .
[or] cooperate with respect to the evaluation of a Participant's
Total Disability or continued Total Disability . . . shall
constitute grounds for termination of benefits under the Plan at
the sole discretion of the Plan Administrator or its authorized
representative."

                                  -20-
(upholding     the   plan    administrator's    decision     to   terminate

disability benefits where evidence on the administrative record

reasonably supported such a decision); Leahy v. Raytheon Co., 315

F.3d   11,   19-20   (1st   Cir.   2002)   (holding   that   where   a   plan

administrator makes a decision supported by substantial evidence,

that decision cannot properly be deemed arbitrary and capricious).

B.   Whether Appellees Improperly Relied on Non-Medical Evidence

             Ortega further claims that the denial of his benefits was

improper because the plan administrator's decision rested on the

findings of a physical therapist rather than those of a physician.

According to Ortega, the Plan's terms require a medical evaluation

to be conducted by a physician prior to the denial of long-term

disability benefits.        On that basis, in Ortega's view, Espina's

findings cannot properly support the denial of his benefits because

Espina is not a physician, and thus, could not perform a "medical"

evaluation as required by the Plan.

             This argument fails to carry the day.       Under the Plan's

terms, for purposes of evaluating a claim, the plan administrator

may require a claimant like Ortega to undergo an examination

conducted by a "Plan Provider."9            A "Plan Provider" means "a

Provider selected by . . . the Plan Administrator to examine or

9
    Article IV of the Plan, in relevant part, states: "[i]n
evaluating the claim, the Claims Service Organization may require
additional information from the attending Provider(s) or arrange
for an examination by a Plan Provider at no cost to the
Participant."

                                    -21-
evaluate the Participant's medical condition in order to determine

his/her Total Disability or continuing Total Disability . . . ."

A "Provider," in turn, is defined as "a person who, with respect to

any Participant: (a) is legally licensed to provide health care to

the Participant; (b) provides such care within the scope of his or

her license; and (c) is not a relative or dependent of the

Participant."

           Ortega     does   not       argue    that   Espina,   as   a   physical

therapist, is not "legally licensed to provide health care" to him.

Nor does Ortega argue that conducting the FCE did not constitute

"care within the scope" of Espina's license, or that a physical

therapist cannot examine or evaluate a person's "medical condition"

in order to determine his or her disability status. Rather, Ortega

simply argues that because Espina is not a physician, the FCE did

not constitute a "medical" evaluation.

           Ortega fails to point to any language in the Plan

requiring a "Provider" to be a medical doctor, or stating that an

examination cannot be conducted by a physical therapist or can only

be conducted by a physician.            Instead, Ortega merely repeats his

assertions that an FCE is not a "medical" evaluation, and that only

a   physician   can   perform      a    "medical"      examination.       We   have

repeatedly held that we may disregard such bare, unsupported

assertions on appeal. See, e.g., United States v. Delgado-Marrero,

744 F.3d 167, 203 (1st Cir. 2014)              (stating that the court need not

                                        -22-
consider    "conclusory   allegations"   or    "bare   assertions"   in   an

appellant's brief); United States v. Dellosantos, 649 F.3d 109, 126

n.18 (1st Cir. 2011) (deeming an issue waived in light of the

party's "perfunctory treatment" of a case and "lack of developed

argumentation").

            Even assuming that Ortega had not waived this issue for

want of developed argument, the Plan's text does not support his

position.     Had the Plan's drafters intended evaluations to be

performed solely by medical doctors, they could have selected the

specific terms "physician" or "doctor" rather than a general,

inclusive term such as "provider."            Moreover, there is strong

support in Puerto Rico law for the assertion that a licensed

physical therapist is a person who "is legally licensed to provide

health care," as required by the Plan.         In a Puerto Rico statute

governing the licensing of physical therapists, "physical therapy"

is defined in part as the "treatment" or "prevention" of any human

"disability, injury, illness or other condition of health," "as

well as the administration of neuromuscular tests to aid the

diagnosis or treatment of any human condition."            P.R. Laws Ann.

tit. 20, § 241(1).

            The requirements for a license to practice physical

therapy in Puerto Rico also include the completion of "a course of

study at a school of physical therapy recognized by the . . .

American Medical Association and/or the American Association of

                                  -23-
Physical Therapy."     Id. § 245.   Finally, according to the American

Association of Physical Therapy, physical therapists are "licensed

health care professionals who can help patients reduce pain and

improve or restore mobility."10       Thus, the plan administrator had

a reasonable basis for interpreting the general term "provider" to

encompass licensed physical therapists in Puerto Rico.

           Moreover, Ortega has admitted -- and the Plan's terms

explicitly state -- that the plan administrator has the right to

require one or more FCEs at any time during the claim evaluation

process.    In    a   section   titled     "Exclusions    from   Payment    of

Benefits," the Plan further provides that, "[n]otwithstanding any

other provision of this Plan," "no benefit shall be payable" if a

participant "fails or refuses to cooperate . . . with respect to

any procedure, evaluation, investigation or audit in connection

with this Plan . . . whether performed by the Plan Administrator

. . . or any other delegate of the Plan Administrator."                This

exclusionary     provision   does   not    require   an   "evaluation"      or

"investigation" to be a "medical" examination or evaluation.               Nor

does the provision require that the person conducting an evaluation

be a "provider" as defined in the Plan; instead, the evaluation may

be conducted by "any other delegate" of the plan administrator.

10
    Am. Physical Therapy Ass'n, Who Are Physical Therapists?,
http://www.apta.org/AboutPTs/ (last updated May 23, 2013).

                                    -24-
             Ortega has also conceded that the Plan grants the plan

administrator the discretionary authority to construe and interpret

the Plan's terms.        On that basis, Ortega agrees, as he must, that

the applicable standard of review is the deferential arbitrary-and-

capricious or abuse-of-discretion standard.              See Cusson, 592 F.3d

at 224; Gross, 734 F.3d at 11.          Accordingly, we cannot say that it

was arbitrary, capricious, or an abuse of discretion for the plan

administrator to interpret the Plan's language as permitting the

termination of benefits based on FCE determinations that Ortega was

exaggerating       his   symptoms    and   was    not   cooperating   with   his

evaluation.        Therefore, Ortega's arguments on this issue are

unavailing.

C.   The Effect of Appellees' Failure to Adopt Dr. Ramos's Opinion

             Lastly, Ortega relies on the opinion of his treating

physician, Dr. Ramos, to establish that he was "totally disabled,"

in   order    to    discredit       Espina's     findings   that   Ortega    was

uncooperative during the third FCE.              Ortega asserts that it was

error for the plan administrator to credit Espina's assessment over

that of Dr. Ramos.

             Ortega is correct that a plan administrator "may not

arbitrarily refuse to credit" the opinion of a claimant's treating

physician.    See Black & Decker, 538 U.S. at 834 (emphasis added).

Here, however, Ortega has failed to establish that there was any

such arbitrary rejection of Dr. Ramos's opinion or, indeed, of any

                                       -25-
other   reliable   evidence    supporting     Ortega's    position.        And

Appellees were under no mandate to grant "special weight" to the

opinions of Ortega's attending physician.           See id.

           Essentially, Ortega asks us to hold that the opinion of

Dr. Ramos, as Ortega's attending physician, necessarily controls

over contradictory evidence in the record.               Such a position,

however, flies in the face of our precedent.              See Richards v.

Hewlett-Packard Corp., 592 F.3d 232, 240 (1st Cir. 2010) ("[T]he

opinion of the claimant's treating physician, which was considered,

is not entitled to special deference.") (quoting Orndorf v. Paul

Revere Life Ins. Co., 404 F.3d 510, 526 (1st Cir. 2005)); Morales-

Alejandro,   486   F.3d   at   700   ("[A]   plan   administrator     is   not

obligated to accept or even to give particular weight to the

opinion of a claimant's treating physician.").

           Ortega cites several cases from other jurisdictions in

support of his argument that an attending physician's medical

evaluation should be given more weight than an FCE performed by a

physical therapist or another non-physician.          Ortega's reliance on

these cases is misplaced.       The first district court case relied

upon by Ortega was later remanded by the Eleventh Circuit and then

subsequently vacated upon the parties' settlement.            See Ridge v.

Hartford Life & Accident Ins. Co., 339 F. Supp. 2d 1323 (M.D. Fla.

2004), vacated, No. 8:03CV1871T26EAJ, 2005 WL 889964 (M.D. Fla.

Apr. 7, 2005).     Even if Ridge were not a vacated district court

                                     -26-
case from another circuit, the factual predicate for its holding is

inapposite.     In Ridge, the court found that "[n]othing in the Plan

defines an FCE, and nothing in the Plan permits [the insurer] to

require an FCE."        339 F. Supp. 2d at 1336.    Here, in contrast, the

Plan explicitly provides that "[o]ne or more . . . Functional

Capacity Examination(s) (FCE) may be required at any time during

the claim evaluation process."

            Ortega next relies upon Lamanna v. Special Agents Mut.

Benefits Ass'n, 546 F. Supp. 2d 261 (W.D. Pa. 2008), and Stup v.

UNUM Life Ins. Co. of Am., 390 F.3d 301 (4th Cir. 2004), abrogated

by Williams v. Metro. Life Ins. Co., 609 F.3d 622 (4th Cir. 2010).

Ortega emphasizes the Lamanna court's statement that "tests of

strength such as a functional capacity evaluation ('FCE') can

neither prove nor disprove claims of disabling pain." See Lamanna,

546 F. Supp. 2d at 296. However, Lamanna does not advance Ortega's

cause for at least three reasons.

            First, the court concluded the sentence highlighted by

Ortega as follows: FCEs do not "necessarily present a true picture

in cases involving fibromyalgia where the symptoms are known to wax

and   wane,    thereby     causing   test     results    potentially   to   be

unrealistic measures of a person's ability to work on a regular,

long-term     basis."      Id.   The    record   here,   however,   does    not

establish that Ortega suffers from fibromyalgia.                Second, the

Lamanna court also explained that "[w]hile the amount of fatigue or

                                       -27-
pain an individual experiences may be entirely subjective, the

extent to which those conditions limit her functional capabilities

can be objectively measured."          Id. at 296.       Here, the three FCEs

sought    to   objectively     measure        the   limitations      of   Ortega's

functional capabilities, and all three FCEs involved at least some

indication that Ortega was exaggerating his symptoms or was not

exerting his best efforts.

             Third, the Lamanna court found that there were "numerous

procedural inconsistencies which demonstrate reliance on medical

reviews based on incomplete records, failure to adequately analyze

the reports of Plaintiff's treating physicians, and unrealistic

demands for objective evidence of fibromyalgia and chronic fatigue

syndrome."      Id.   at   288.      The   court     further    found     that   the

administrator's decision was not based on substantial evidence

because "there were significant omissions, mis-interpretations, and

unreasonable expectations in the reports of the medical consultants

upon which [the administrator] relied in reaching its conclusion."

Id. at 289.    By means of contrast, in the record before us, we have

identified     neither     "numerous    procedural      inconsistencies"         nor

"significant     omissions,       mis-interpretations,         and   unreasonable

expectations" in the reports upon which the plan administrator

relied.   Cf. id. at 288-89.

             Ortega cites Stup for the proposition that because the

FCE in that case "lasted only two and a half hours, . . . the FCE

                                       -28-
test results do not necessarily indicate Stup's ability to perform

sedentary work for an eight . . . hour workday, five days a week."

Stup, 390 F.3d at 309.         Unlike the instant case, however, the

claimant    in    Stup   had   provided     the   insurer      with    years    of

"substantial medical evidence supporting her diagnosis," id. at

311, and the only evidence to the contrary was "[a]n equivocal

opinion" that was "based on ambiguous test results."                  Id. at 310.

            The    physical    therapist     in   Stup    "twice        expressly

recognized the ambiguity of the FCE results and hedged her negative

interpretation of them." Id. The therapist in that case concluded

her report by warning "that it would not be 'prudent' to use the

FCE results to determine Stup's ability to perform 'specific job

duties.'"    Id.     Here, on the other hand, Espina unequivocally

concluded    that    Ortega    was    exaggerating       his    symptoms       and

disabilities.      Espina reported that Ortega failed eighteen out of

twenty-one validity criteria, indicating a significant lack of

cooperation with the evaluation -- a determination that constitutes

grounds for termination of benefits under the Plan.                    Thus, the

reasoning embraced by Stup does not control the result here.

            Moreover, all three cases relied upon by Ortega on this

issue presumed that a heightened standard of review applies if the

defendant has a structural conflict of interest.               See id. at 307,

311 (applying a less-deferential standard of review because the

defendant "acted under a conflict of interest" -- its dual role as

                                     -29-
both payer of benefits and arbiter of claims meant that "its

decision to deny benefits impacted its own financial interests");

Lamanna, 546 F. Supp. 2d at 286 (applying "a moderately heightened

level of scrutiny" because of the particular conflict of interest

caused by the relationship between the claims administrator and the

insurer); Ridge, 339 F. Supp. 2d at 1334 ("Because Hartford, as

claims administrator, is also the insurance company responsible for

paying the claims, the heightened arbitrary and capricious standard

[would be] applicable . . . . [if] Hartford operated under a

conflict of interest.").

           However, the Supreme Court has since clarified that the

presence of a conflict of interest does not alter the standard of

review, but rather is "but one factor among many that a reviewing

judge must take into account."      Metro. Life Ins. Co. v. Glenn, 554

U.S. 105, 116 (2008).       Thus, the standard of review here remains

the deferential abuse-of-discretion standard. See id.; Cusson, 592

F.3d at 224.     While a conflict of interest "can, under certain

circumstances, be accorded extra weight in the court's analysis,"

Cusson,   592   F.3d   at   224,   Ortega   does   not   argue   that   such

circumstances are present here.

           Contrary to Ortega's arguments, we have previously held

that an administrator's decision to terminate disability benefits

was not arbitrary and capricious even where that decision was

supported in part by an FCE conducted by a physical therapist and

                                    -30-
was   directly   contradicted    by   the   claimant's   two   treating

physicians.   See Gannon, 360 F.3d at 213-16.       The administrator's

decision in Gannon was supported by: an FCE conducted by a physical

therapist; the opinion of an "independent medical consultant who

reviewed [the claimant's] file"; a transferable skills analysis

prepared by a vocational consultant; a surveillance report; and the

denial of Gannon's claim for social security disability benefits.

Id. at 213-15.

          As in the case at hand, the FCE in Gannon "indicated that

[the claimant] did not put forth her maximum effort during the

tests . . . and that her performance was inconsistent in various

ways."   Id. at 213.   The FCE provided evidence that the claimant

was exaggerating her symptoms and that she was physically capable

of performing restricted work activities.     Id.    Given the findings

of the FCE and conclusions of the physical therapist, we found it

reasonable for the plan administrator to rely upon the FCE as

evidence in support of its determination that Gannon was not

"disabled" under the Plan.      Id.

          Similarly, the Tenth Circuit has held that the results of

two FCEs -- both administered by physical therapists -- provided

substantial evidence upon which the plan administrator could have

based its decision to deny benefits.        Buckardt v. Albertson's,

Inc., 221 F. App'x 730, 735-37 (10th Cir. 2007). Much like Ortega,

the plaintiff in Buckardt argued that the "FCEs were not medical

                                  -31-
evaluations" and that an FCE administered by a physical therapist

cannot provide substantial evidence for a decision to terminate

benefits.   Id. at 735-36.     The Tenth Circuit disagreed, reasoning

that such a position is contrary to the prevailing precedent in

several circuits.    Id. at 736 (citing Gannon, 360 F.3d at 213, and

Jackson v. Metro. Life Ins. Co., 303 F.3d 884, 888 (8th Cir.

2002)).

            The   Eleventh   Circuit   has   also   addressed   a   similar

argument from a claimant maintaining that an FCE from a physical

therapist should not have been given more weight than the opinion

of the claimant's treating physician.           See Townsend v. Delta

Family-Care Disability & Survivorship Plan, 295 F. App'x 971, 977

(11th Cir. 2008). In rejecting this argument, the Eleventh Circuit

reasoned that "FCEs are routinely conducted by physical therapists"

and "plan administrators routinely rely on FCEs."           See id.; see

also Duncan v. Fleetwood Motor Homes of Ind., Inc., 518 F.3d 486,

489 (7th Cir. 2008); Baker v. Barnhardt, 457 F.3d 882, 885-86 (8th

Cir. 2006).       Thus, we have not found compelling support for

Ortega's argument that a plan administrator cannot rely on the

findings of an FCE conducted by a physical therapist.

            Even if we were inclined to accept Ortega's theory that

a medical doctor's opinion must be given more weight than the

opinion of a non-physician, the record here also contains the

opinions of medical doctors that support the plan administrator's

                                  -32-
decision.      As previously summarized, Dr. Seín found -- in two

successive FCEs -- that Ortega demonstrated sub-par effort as well

as inconsistencies between his reported pain and his physical

movements.      During each FCE, Ortega also refused to perform some

tests.    Reviewing the results of the second FCE conducted by

Dr.   Seín,    Dr.   Ocasio   initially    recommended    denying   Ortega's

benefits due to his lack of cooperation.         Additionally, Dr. Rivera

concluded     that   Ortega   provided     "unreliable"   information    and

exaggerated his psychiatric symptoms.         Therefore, the record shows

that the opinions of several doctors provide further support for

the plan administrator's decision.

              We have previously held that the mere existence of

contrary medical evidence does not render arbitrary and capricious

a plan administrator's decision to credit one opinion over another.

See Gannon, 360 F.3d at 213. "Indeed, when the medical evidence is

sharply conflicted, the deference due to the plan administrator's

determination may be especially great."         Leahy, 315 F.3d at 19.

              The plan administrator here reviewed and considered

Dr. Ramos's findings, but it ultimately concluded that other

evidence in the administrative record -- including Espina's report

that Ortega was uncooperative and exaggerating his symptoms -- was

more persuasive.      On that basis, the administrator exercised its

discretion to determine that Ortega was no longer eligible to

receive plan benefits for his alleged continuing disability.             See

                                    -33-
Medina, 588 F.3d at 46 ("[I]n the presence of conflicting evidence,

it is entirely appropriate for a reviewing court to uphold the

decision of the entity entitled to exercise its discretion."

(quoting Gannon, 360 F.3d at 216)).       Such a conclusion, supported

by substantial evidence, is neither arbitrary, nor capricious, nor

an abuse of discretion. See Leahy, 315 F.3d at 18-19 (finding that

where a plan administrator's determination that the insured was not

fully disabled rests on substantial evidence, it cannot be said

that such a decision is arbitrary and capricious).

                            III.   Conclusion

             Given the contents of the administrative record, the plan

administrator's finding that Ortega was uncooperative during his

final FCE -- and thus ineligible for continuing benefits -- was

reasonable     and   supported     by   substantial   evidence.       The

administrator's decision to terminate Ortega's long-term disability

benefits was, therefore, neither arbitrary nor capricious.          In so

doing, the administrator also did not abuse its discretion to

construe and interpret the Plan's terms and determine whether there

existed grounds for termination of Ortega's benefits.             For the

foregoing reasons, we affirm the judgment of the district court.

             AFFIRMED.

                                   -34-