Matias-Correa v. Pfizer, Inc.

• Court: U.S. Court of Appeals — First Circuit
• Writing for the Court: Howard
• Citation: Matias-Correa v. Pfizer, Inc., 345 F.3d 7 (1st Cir. 2003)
• Decision Date: 25 September 2003
• Docket Number: No. 03-1032.,03-1032.
• Parties: Nancy MATIAS-CORREA, Plaintiff, Appellant, v. PFIZER, INC.; Medical Card Systems, Inc., Defendants, Appellees.

345 F.3d 7

Nancy MATIAS-CORREA, Plaintiff, Appellant, v. PFIZER, INC.; Medical Card Systems, Inc., Defendants, Appellees.

No. 03-1032.

United States Court of Appeals, First Circuit.

Submitted May 12, 2003.

Decided September 25, 2003.

COPYRIGHT MATERIAL OMITTED

Raymond L. Sanchez Maceira for appellant.

Carl Schuster, with whom Lourdes C. Hernández-Venegas and Schuster, Usera & Agulió LLP, were on brief for appellees.

Before Lynch, Lipez, and Howard, Circuit Judges.

HOWARD, Circuit Judge.

Plaintiff-appellant Nancy Matías-Correa appeals the district court's entry of summary judgment in favor of defendants-appellees Pfizer, Inc. ("Pfizer"), and Medical Card System, Inc. ("MCS"), in a suit in which Matías alleged that the termination of her disability benefits violated the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461. We affirm.

I. Factual and Procedural Background

Matías worked as a machine operator for Pfizer (formerly Warner-Lambert) in a Puerto Rico facility, starting as a temporary employee in 1986 and working on a permanent basis from September 1988 until November 1995. While employed by Pfizer, Matías participated in Pfizer's Long Term Disability Benefits Plan, which provides disability benefits for participants who are "totally disabled." A participant is considered totally disabled under the terms of the plan if, during the first two years of disability, she is "unable to perform the basic duties of [her] occupation, and [is] not involved in any other gainful occupation." After receiving plan benefits for two years, however, a participant will only be considered totally disabled if she is "unable to work in an occupation or job for which [she is] qualified or may be qualified based on [her] academic background, training or experience." MCS acted as claims administrator for the plan.

In April 1996, Matías applied for and was granted disability benefits under the plan, based on her condition of low back pain syndrome, radiculopathy, and depression. At the time, her condition satisfied the plan's first definition of "total disability."

After two years passed, however, Matías could only continue to receive benefits if her physical condition satisfied the second definition of total disability.¹ Under the terms of the plan, a participant receiving benefits "may be required to undergo a medical examination ... and/or to submit evidence of continued Total Disability satisfactory to [MCS] ... to determine [her] continued entitlement to disability benefits or ability to resume active employment." Further, such a participant would periodically "be required to submit evidence to [MCS] of [her] continued total disability," and refusal to submit such evidence would result in the discontinuation of benefits.

On April 6, 2001, MCS requested that Matías submit copies of all medical records and progress notes of her treating doctors. Matías complied, submitting records from a variety of medical professionals, including her rheumatologist, neurologist, and psychiatrist. MCS referred Matías's file to Dr. José Ocasio, an independent occupational medical consultant, for an independent medical evaluation. On May 14, 2001, Dr. Ocasio made a preliminary finding that Matías's records did not indicate total disability. He noted that Matías did not appear to be following a regular treatment schedule with her physicians, and recommended a Functional Capacity Evaluation ("FCE").

Matías's FCE showed that she was able to work at a "sedentary physical demand level" during an eight-hour day. The tests suggested symptom exaggeration by Matías and "very poor effort or voluntary sub-maximal effort which is not necessarily related to pain, impairment or disability." Based on these results and his prior findings, Dr. Ocasio recommended the termination of Matías's disability benefits on the ground that she was not totally disabled. MCS terminated Matías's disability benefits, effective June 15, 2001.

On August 3, 2001, Matías filed a first-level appeal of her benefits termination with MCS. As part of this appeal, she submitted additional medical documents, including three undated doctors' assessments of her physical capabilities during an eight-hour workday. These "Residual Functional Capacity Assessments" ("RFC Assessments") varied in their conclusions as to the amount of activity Matías could tolerate. For example, one doctor estimated that Matías could sit for less than one hour and stand for less than one hour, while another estimated that she could sit for two to four hours and stand for one to two hours. All found that Matías needed rest periods during the day.

MCS referred Matías's full medical file, including the new documents submitted on appeal, to Dr. Ocasio for evaluation, and on August 13, 2001, Dr. Ocasio once again recommended the termination of Matías's benefits. He found that the additional materials confirmed that Matías was not totally disabled, concluding in particular that all three RFC Assessments indicated that Matías could work for short periods of time, with rest. Two days later, MCS affirmed its termination of Matías's benefits, notifying her that she did not meet the definition of "totally disabled" under the plan. MCS concluded that although Matías suffered from several physical conditions that required treatment, she was able to work. MCS also informed Matías of her right to appeal the decision by submitting any additional evidence she wished to have considered.

Matías requested a second-level appeal, and on October 12, 2001, she submitted updated progress notes from her psychiatrist, Dr. José Bisbal, and the results of an MRI performed on her right knee.² She also resubmitted a number of the medical documents she had already provided as part of her initial review and first appeal. Dr. Ocasio again reviewed Matías's medical evidence, and concluded that she was not "totally disabled." On October 30, 2001, MCS issued its final denial of Matías's appeal, and affirmed the termination of her benefits.

In November 2001, Matías filed suit against Pfizer and MCS in the United States District Court for the District of Puerto Rico, claiming a violation of ERISA based on the termination of her benefits. Matías claimed that she suffered from debilitating conditions and that MCS's decision to terminate her benefits was arbitrary and capricious. In September 2002, Pfizer and MCS moved for summary judgment on the ground that the benefits determination was supported by substantial evidence in the record. In November 2002, the district court entered judgment in favor of defendants. The court found that (1) the standard of review was arbitrary and capricious because the plan granted the necessary discretionary authority to MCS; and (2) MCS had not acted arbitrarily or capriciously in light of substantial record evidence supporting MCS's termination of benefits. This appeal followed.

II. Analysis

A. The ERISA Standard of Review

Matías alleges that the district court erred in reviewing MCS's benefits determination under an "arbitrary and capricious" standard. Such a standard of review is appropriate where the language of the benefits plan reflects a "clear grant of discretionary authority to determine eligibility for benefits." Leahy v. Raytheon Co., 315 F.3d 11, 15 (1st Cir.2002) (citing Terry v. Bayer Corp., 145 F.3d 28, 37 (1st Cir.1998)); see Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989).

The plan states that MCS "shall administer claims under the Plan," and

[S]hall have the power and the duty, including discretionary authority, to take all actions and to make all decisions necessary or proper to carry out the provisions of the Plan, including, but not limited to, the following:

* * * * * *

To interpret the Plan to determine whether a claimant is eligible for benefits, to decide the amount, form, and timing of benefits, and to resolve ambiguities, inconsistencies, omissions and any other claim-related matters under the Plan which is [sic] raised by a claimant or identified by the Investment Committee, its interpretation and resolution to be final, conclusive and binding on all parties affected thereby

App. at 69-70 (emphasis added).

Despite this language, Matías alleges that...