ERISA-First Circuit Upholds Employer’s/Administrator’s Decision To Terminate Disability Benefits

In Rolando Ortega-Candelaria v. Johnson & Johnson, No. 13-1564 (1st Cir. 2014), plaintiff Ortega was appealing the district court’s dismissal of his claims under ERISA. Before the district court, Ortega sought judicial review of the decision to terminate payment of disability benefits to him under the Johnson & Johnson 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 argued that his employer, Johnson & Johnson, and the Plan’s administrator, 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. In analyzing the case, the First Circuit Court of Appeals (the “Court”) said that, 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. Further, Ortega was uncooperative during a functional capacity examination, failing to use his best efforts to complete required tasks, thereby invoking a Plan provision under which his benefits could be terminated on account of such failure. The Court concluded that, given the substantial record evidence supporting the Appellees’ determination, the decision to terminate Ortega’s benefits did not constitute an abuse of discretion and was neither arbitrary nor capricious. As such, the Court affirmed the district court’s decision.

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