Ortega-Candelaria v. Johnson & Johnson, 755 F.3d 13

Ortega(Candelaria) sought ERISA judicial review of a district court decision terminating his long-term disability benefits under Johnson & Johnson's Plan.
The Plan grants the administrator discretion to construe the Plan and determine eligibility for benefits, and permits evaluations including FCEs/IME as part of claim processing.
Ortega's disability claim covered physical and mental health conditions; Ortega alleges benefits were wrongfully terminated for lack of cooperation and exaggerated symptoms.
Espina (a physical therapist) conducted a November 16, 2004 FCE and found Ortega exaggerated symptoms and showed very poor effort; Ortega refused many tasks.
Dr. Seín performed two prior FCEs finding subpar effort; Dr. Ramos (treating physician) opined Ortega was totally disabled, but the administrator credited Espina's findings over Ramos.
The district court granted judgment on the administrative record in favor of the Plan; the First Circuit affirmed, applying deferential abuse-of-discretion review and substantial-evidence standard.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Was the termination of benefits arbitrary and capricious given Ortega's cooperation evidence?	Ortega argues lack of cooperation was not proven; disputes reliance on Espina.	Appellees contend Ortega failed to cooperate; Espina's findings are substantial.	No; termination supported by substantial evidence of noncooperation.
May the Plan rely on Espina's non-physician FCE over treating physicians' opinions?	Espina is not a medical doctor; physician opinions should prevail.	Plan allows FCEs by Plan Providers, including non-physicians; not limited to doctors.	Yes; Plan permits non-physician FCEs; decision not arbitrary for relying on Espina.
Did the Plan abuse its discretion by not giving special weight to Dr. Ramos's opinion?	Ramos's treating-physician opinion should control or carry weight.	Plan may credit conflicting evidence and is not required to give special weight to treating physicians.	No; administrator may credit other reliable evidence; not required to defer to Ramos.

Gannon v. Metro. Life Ins. Co., 360 F.3d 211 (1st Cir. 2004) (confirms deference when evidence is conflicting and substantial)
Medina v. Metro. Life Ins. Co., 588 F.3d 41 (1st Cir. 2009) (upholds deference when evidence supports administrator’s decision)
Morales-Alejandro v. Med. Card Sys., Inc., 486 F.3d 693 (1st Cir. 2007) (no special weight to treating physician; substantial evidence standard)
Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack Anesthesia Assocs. Long Term Disability Plan, 705 F.3d 58 (1st Cir. 2013) (emphasizes substantial evidence and reasonableness under deferential review)
Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (S. Ct. 2008) (confirms that conflict of interest is only a factor, not a standard shift)
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (Supreme Court 1989) (establishes deferential review when Plan grants discretion)
Black & Decker Disability Plan v. Nord, 538 U.S. 822 (Supreme Court 2003) (treating physician evidence not automatically controlling)
Leahy v. Raytheon Co., 315 F.3d 11 (1st Cir. 2002) (confirms substantial evidence standard applies when discretionary)