Bilheimer v. Federal Express Corp. Long Term Disability Plan ( 2015 )

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 13-1859
RICHARD BILHEIMER,
Plaintiff – Appellee,
v.
FEDERAL EXPRESS CORPORATION LONG TERM DISABILITY PLAN,
Defendant – Appellant.
-----------------------------
GEORGE W. HICKS, JR.,
Amicus Curiae.
Appeal from the United States District Court for the District of
South Carolina, at Greenville. G. Ross Anderson, Jr., Senior
District Judge. (6:12-cv-00383-GRA)
Argued: March 26, 2015 Decided: May 5, 2015
Before DIAZ, FLOYD, and THACKER, Circuit Judges.
Affirmed by unpublished per curiam opinion.
ARGUED: David P. Knox, FEDERAL EXPRESS CORPORATION, Memphis,
Tennessee, for Appellant. George W. Hicks, Jr., BANCROFT, PLLC,
Washington, D.C., as Court-Assigned Amicus Counsel.
Unpublished opinions are not binding precedent in this circuit.
PER CURIAM:
Federal Express Corporation Long Term Disability Plan 1
appeals the district court’s award of summary judgment in favor
of Richard Bilheimer (“Appellee”). Following multiple
accidents, Appellee applied for and received disability
benefits. However, Appellant eventually denied further long-
term benefits -- a decision Appellee sought to have reviewed by
the courts. Reviewing the denial of benefits de novo, the
district court held that the weight of the evidence indicated
Appellee was totally disabled and thus entitled to receive
disability benefits.
We affirm the district court’s decision to review the
denial of benefits de novo because Appellee’s claim was not
reviewed and denied by an entity with discretionary authority
over appeals. We further affirm the district court’s conclusion
that Appellee is entitled to receive disability benefits because
the district court did not err by determining Appellee fell
within the Plan’s definition of “totally disabled.”
1
Federal Express Corporation Long Term Disability Plan is
both a party and the proper name of the benefits plan at issue.
For clarity, we refer to it as “Appellant” when we discuss its
status as a party; we refer to it as the “Plan” when we discuss
its status as a benefits plan.
2
I.
A.
Federal Express Corporation (“FedEx”) established the
Plan to ensure the funding and availability of long-term
disability benefits for its employees. Pursuant to the Plan,
FedEx established the Retirement Plan Investment Board (“Board”)
“to perform the administrative duties hereunder other than
administration of claims.” J.A. 460. 2 The Plan also outlines
the benefits review process, providing for initial and appellate
review of an individual’s claim.
Aetna Life Insurance Company (“Aetna”) serves as the
claims-paying administrator for the Plan. As claims-paying
administrator, Aetna initially determines whether an individual
is entitled to receive benefits under the Plan. If an
individual is denied benefits at this stage, he or she may
appeal the initial denial.
Appeals of benefits denials are handled by an appeal
committee. FedEx, the administrator of the Plan, is charged
with appointing this appeal committee. Originally, FedEx
appointed its internal Benefit Review Committee to serve as the
appeal committee. In July 2008, however, the director of
2
Citations to the “J.A.” refer to the contents of the Joint
Appendix filed by the parties in this appeal.
3
FedEx’s Employee Benefits Department recommended that the Board
“outsource all [long-term disability] appeals to Aetna.” J.A.
58-59. The Board approved this recommendation, thus ceasing
operation of the Benefit Review Committee. But the Board’s
minutes from the meeting do not expressly state that the Board
was appointing Aetna as the appeal committee contemplated under
the Plan. 3
To institute this change, FedEx and Aetna amended
their service agreement. Under the amended agreement, Aetna
became “fully responsible for final appeal benefit
determinations for the Short Term Disability Plans, and . . .
for Long Term Disability Plans.” J.A. 65.
B.
Appellee was employed by FedEx from 1997 to 2005 and,
during this time, was a full-time senior safety specialist. As
a FedEx employee, Appellee participated in the Plan. While
employed by FedEx, Appellee sustained various injuries in two
separate automobile accidents -- one in 2001 and another in
2005.
3
Rather, the minutes state that the Board “approve[d] the
recommendation” to “outsource remaining long-term disability
appeals effective September 1, 2008, and effectively cease the
operation of the Benefit Review Committee.” J.A. 63.
4
The second accident caused substantial and lasting
injuries. Appellee was left unable to work, prompting the end
of his employment with FedEx. In the years that followed,
Appellee sought treatment from and was examined by numerous
doctors. These doctors diagnosed Bilheimer with -– and treated
him for -– various medical conditions, including:
chronic pain syndrome, degenerative disc
disease, carpal tunnel syndrome, high blood
pressure, obstructive sleep apnea,
temporomandibular joint disorder[,] . . .
cervical radiculitis, and obesity. In 2008,
a magnetic resonance imaging . . . showed
that [Appellee] had multiple herniated
discs. Also in 2008, [Appellee] underwent a
nerve conduction and electromyography . . .
study which revealed that he suffered from
chronic cervical radiculitis and that he had
borderline carpal tunnel syndrome.
J.A. 2.
Appellee received short-term benefits from December 9,
2005, to June 8, 2006. After his short-term benefits ended, he
applied for long-term benefits under the Plan. He received
temporary long-term benefits under the Plan from June 9, 2006,
to June 8, 2008.
C.
Although Appellee received twenty-four months of long-
term benefits, Aetna -- in its capacity as claims administrator
for the Plan -- denied further benefits because Appellee’s
“medical condition [did] not meet the definition of Total
5
Disability” under the Plan. J.A. 81. Specifically, Aetna
concluded that Appellee failed to prove that his disability
prevented him from engaging “in any compensable employment for
twenty-five hours per week.” J.A. 414. In support of his
benefits claim, Appellee offered the medical opinions of Dr.
Peter Morris and Dr. Glendon Rougeou. Dr. Morris, who conducted
a comprehensive examination of Appellee as part of a Social
Security Disability Insurance evaluation, determined “that in an
eight-hour workday, [Appellee] could be expected to stand and/or
walk for two hours at most, and to sit for four hours maximum,
with a break every hour.” J.A. 19. And Dr. Rougeou, who also
conducted a physical examination and provided continuous care to
Appellee, concluded Appellee was totally disabled:
It is my opinion, based upon my medical
education and experience and based upon my
specific knowledge of [Appellee’s] problems
and treatment history that he is and has
been completely and totally disabled from
performing any employment on a part-time
(twenty-five hours per week) or full-time
basis, consistent with the definition of
disability above. I render my opinion based
upon the cumulative effect of [Appellee’s]
above described objectively diagnosed
medical problems and the subjective symptoms
he suffers.
Id. at 91.
Despite the opinions of Dr. Morris and Dr. Rougeou,
Aetna’s peer review physicians determined Appellee was not
totally disabled, per the Plan’s requirements. See, e.g., J.A.
6
309 (“[T]here is no significant objective clinical documentation
that reveals a functional impairment that would preclude the
claimant from engaging in any compensable employment for a
minimum of 25 hours a week from 6/9/08 to current.”).
Appellee then sought review of this determination
through the process established in the Plan. Acting in its
appellate capacity per the amended service agreement, an “Aetna
Appeal Review Committee” again accepted the findings of the
Aetna doctors and upheld the initial denial of continued long-
term benefits.
D.
Appellee then filed a complaint in the district court
challenging the denial of benefits pursuant to the Employee
Retirement Income Security Act (“ERISA”). At the case’s outset,
Appellee and Appellant each filed a motion for partial summary
judgment regarding the appropriate standard of review.
Appellee claimed the district court should review the denial de
novo because FedEx was not permitted to delegate to Aetna
discretionary appellate review of benefits claims. See
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)
(explaining that, when an ERISA claimant is denied benefits, the
denial of benefits is reviewed de novo “unless the benefit plan
gives the administrator or fiduciary discretionary authority to
determine eligibility for benefits or to construe the terms of
7
the plan”). Appellant claimed that FedEx modified the Plan to
provide Aetna with this authority or, in the alternative, that
FedEx appointed Aetna as the appeal committee. Therefore,
Appellant argued, the abuse-of-discretion standard of review was
appropriate.
First, the district court concluded FedEx was not
authorized to delegate its discretionary authority:
[I]n this case, the Service Agreement
evidences an explicit delegation of
authority to Aetna; however, the [Plan] does
not authorize such a delegation. . . .
[T]he [Plan] was not properly modified to
allow for delegation; thus, delegation
remains improper, even though the Service
Agreement explicitly stated that a
delegation had been made.
J.A. 35; Belheimer [sic] v. Fed. Express Corp. Long Term
Disability Plan, No. 6:12-00383, 2012 WL 5945042 (D.S.C. Nov.
28, 2012). Second, the district court concluded FedEx merely
outsourced the appeals process to Aetna and did not appoint a
new appeal committee. Accordingly, the district court reviewed
the denial of benefits de novo.
In a subsequent order addressing the denial of
benefits, the district court thoroughly reviewed the opinions
offered by the myriad doctors and peer review physicians.
First, the district court found the opinions and limitations
discussed by Dr. Morris and Dr. Rougeou “more persuasive than
those of the doctors that prepared physician review reports” per
8
Aetna’s request. J.A. 19. Second, the district court
determined that “total disability” -- and the requirement that
Appellee be able to engage in “compensable employment” -- could
not be narrowly construed, adopting the Sixth Circuit’s
interpretation of similar language:
[T]he Court finds that the phrase “any
compensable employment” should not “be
construed so narrowly that an individual
must be utterly helpless to be considered
disabled . . . . [N]ominal employment, such
as selling peanuts or pencils which
would yield only a pittance, does not
constitute[]” compensable employment.
Id. at 22–23 (quoting VanderKlok v. Provident Life & Accident
Ins. Co. Inc., 956 F.2d 610, 615 (6th Cir. 1992)) (first and
second alterations in original). So the district court
concluded the limitations expressed by Dr. Morris precluded
Appellee from engaging in “compensable employment.”
Based on these findings and conclusions, the district
court held “that the weight of the evidence indicates that
[Appellee] has the complete inability to engage in any
compensable employment for twenty-five hours per week and is
thus totally disabled.” J.A. 23. The district court ordered
Appellant to award benefits to Appellee. Appellant filed a
timely appeal.
9
II.
Appellant attacks the judgment of the district court
on two fronts.
First, Appellant contends the district court erred
when it reviewed the denial of benefits de novo because Aetna
had discretionary authority to decide benefits appeals. We
review this issue de novo. See Haley v. Paul Revere Life Ins.
Co., 77 F.3d 84, 89 (4th Cir. 1996) (determining de novo review
is appropriate standard of review when deciding “whether the
[ERISA] plan confers discretion upon the administrator to make
the decision at issue”).
Second, Appellant claims the district court erred when
it determined Appellee was totally disabled, as defined by the
Plan. Because we find the district court correctly reviewed
Appellee’s benefits eligibility de novo, we employ the same
standard. See Williams v. Metro. Life Ins. Co., 609 F.3d 622,
629 (4th Cir. 2010). We “review factual findings for clear
error, and legal conclusions de novo.” Paese v. Hartford Life &
Accident Ins. Co., 449 F.3d 435, 442 (2d Cir. 2006) (emphasis
omitted).
III.
A.
Before we examine the district court’s “total
disability” determination, we must pass judgment on the district
10
court’s resort to de novo review. When an ERISA claimant is
denied benefits, the denial of benefits is reviewed de novo
“unless the benefit plan gives the administrator or fiduciary
discretionary authority to determine eligibility for benefits or
to construe the terms of the plan.” Firestone Tire & Rubber Co.
v. Bruch, 489 U.S. 101, 115 (1989). “If such discretionary
authority is conferred, the courts’ review is for abuse of
discretion; however, the default standard of review is de novo,
and abuse-of-discretion review is appropriate only when
discretion is vested in the plan administrator.” Johnson v. Am.
United Life Ins. Co., 716 F.3d 813, 819 (4th Cir. 2013)
(internal quotation marks omitted).
An ERISA plan can confer discretion (1) by language
that “expressly creates discretionary authority” or (2) by terms
that “create discretion by implication.” Feder v. Paul Revere
Life Ins. Co., 228 F.3d 518, 522-23 (4th Cir. 2000). Regardless
of whether discretion is created expressly or implicitly, a plan
must manifest a clear intent to confer such discretion. Woods
v. Prudential Ins. Co. of Am., 528 F.3d 320, 322 (4th Cir.
2008); see also Cosey v. Prudential Ins. Co. of Am., 735 F.3d
161, 165 (4th Cir. 2013).
On appeal, the parties agree that the Plan confers
discretion upon two entities: FedEx and the “appeal committee”
appointed by FedEx. They dispute, however, whether the Plan
11
also grants Aetna that authority. Appellant argues Aetna had
discretionary authority because either FedEx appointed Aetna as
the appeal committee pursuant to the Plan or FedEx modified the
Plan. We reject both arguments, finding Aetna did not have
discretionary authority to determine whether Appellee was
entitled to benefits.
1.
The Plan provides that FedEx shall appoint an
appeal committee and vests this committee with discretionary
authority. In particular, section 5.3(c) of the Plan provides
that FedEx “shall appoint an appeal committee for the purpose of
conducting reviews of denial of benefits and providing the
claimant with written notice of the decision reached by such
committee.” J.A. 450. The authority of the appeal committee is
established by section 5.3(d) of the Plan:
The appeal committee . . . shall, subject to
the requirements of the Code and ERISA, be
empowered to interpret the Plan’s provisions
in its sole and exclusive discretion in
accordance with its terms with respect to
all matters properly brought before it . . .
including, but not limited to, matters
relating to the eligibility of a claimant
for benefits under the Plan. The
determination of the appeal committee shall
be made in a fair and consistent manner in
accordance with the Plan’s terms and its
decision shall be final, subject only to a
determination by a court of competent
jurisdiction that the committee’s decision
was arbitrary and capricious.
12
Id. at 453–54. Appellant claims Aetna was appointed as the
appeal committee because the Board disbanded the Benefit Review
Committee, the Board decided to outsource appeals to Aetna, and
FedEx and Aetna amended their service agreement. Accordingly,
Appellant argues, Aetna had discretionary authority to grant or
deny benefits.
2.
This claim turns on the meaning of “appoint,” raising
a question of interpretation. We interpret ERISA plans just as
we interpret contracts and trusts. See Johnson v. Am. United
Life Ins. Co., 716 F.3d 813, 819 (4th Cir. 2013). We enforce
the terms of an ERISA plan “according to the literal and natural
meaning of the [p]lan’s language.” Id. at 820 (internal
quotation marks omitted). We look at the plan “as a whole and
determine the provision’s meaning in the context of the entire
agreement.” Id. But when “the language of a contract is fairly
and reasonably susceptible to either of the constructions
asserted by the parties,” the terms remain ambiguous and must be
construed in favor of the claimant. Id. (internal quotation
marks omitted).
Here, the Plan does not detail the process for
appointing the appeal committee. Without guidance from the
Plan, each party offers its own definition of “appoint.”
Because the Board outsourced appeals to Aetna, Appellee seeks to
13
exclude “outsource” from this definition while Appellant seeks
to include “outsource” as part of its definition. Appellee
argues that appointment requires a selection or designation
process designed to fill an office; this definition does not
include outsourcing because outsourcing is simply the channeling
of work from one place to another. Appellant responds that the
semantic differences between “appoint” and “outsource” are
meaningless, claiming the terms are functionally
indistinguishable.
Both definitions prove reasonable. On one hand,
“appoint” means there is some selection and designation
process. See, e.g., The American Heritage Dictionary 87 (5th
ed. 2011) (defining “appoint” as “[t]o select or designate to
fill an office or a position”); see also Garner’s Dictionary of
Legal Usage 269 (3d ed. 2011) (“Appoint implies selection that
may be subject to others’ approval but will not require a
general vote of the electorate.”). On the other hand, “appoint”
may mean assignment of a job without any process-related
component, which potentially includes outsourcing. See, e.g.,
New Oxford American Dictionary 76 (3d ed. 2010) (defining
“appoint” as “assign a job or role to (someone)”); see also New
Oxford American Dictionary 1246 (3d ed. 2010) (defining
“outsource” as “obtain (goods or a service) from an outside or
foreign supplier, esp. in place of an internal source”).
14
When, as here, the terminology is reasonably
susceptible to either construction, we construe the language in
favor of the claimant. See Johnson, 716 F.3d at 820.
Accordingly, “appoint” incorporates the notion of a selection
and designation process. “Appoint” does not include
outsourcing, which is a mere funneling of work. Therefore, in
order to comply with the Plan the Board needed to actually
designate Aetna as the appeal committee. The evidence does not
demonstrate that the Board exercised this power. Instead, the
Board merely approved an internal memorandum from FedEx’s
Employee Benefits Department recommending that all appeals be
farmed out to Aetna; there was not a process indicating a
selection and designation of a new appeal committee. Indeed,
the Board’s minutes do not expressly mention Aetna, much less
the Aetna Appeal Review Committee that decided Appellee’s
appeal. So the Board did not actually appoint Aetna as the
appeal committee and thus did not give it discretionary
authority over appeals. 4
4
To the extent the minutes can be construed as actually
approving the outsourcing of appeals to Aetna, we note that
Aetna itself is not a committee as that term is commonly
understood. See New Oxford American Dictionary 349 (3d ed. 2010)
(defining “committee” as a “a group of people appointed for a
specific function”); see also Black’s Law Dictionary 309 (9th
ed. 2009) (defining “committee” as “a subordinate group to which
a[n] . . . organization refers business for consideration,
investigation, oversight, or action”). Rather, Aetna itself
(Continued)
15
3.
Alternatively, Appellant claims the Plan was
effectively amended because the Board disbanded the Benefit
Review Committee and outsourced appeals to Aetna and because
FedEx and Aetna amended their service agreement. Section 7.1 of
the Plan outlines the amendment process:
The Sponsoring Employers shall have the
right at any time to modify, alter or amend
the Plan in whole or in part by an
instrument in writing duly executed by
officers of each of the Sponsoring Employers
or as reflected in the minutes of FedEx
Corporation’s board of directors or any
committee thereof or as reflected in the
minutes of the [Board].
J.A. 463. 5
Appellant contends this modified section 5.3(c) of the
Plan, which covers appointment of the appeal committee, because
it dissolved the Benefit Review Committee and moved
discretionary appellate review to Aetna.
later created a committee, the Aetna Appeal Review Committee, to
review and decide appeals. Construing the terms of the Plan in
Appellee’s favor, the distinction between Aetna generally and
the Aetna Appeal Review Committee is not without a difference.
5
The Plan defines “Sponsoring Employee” as “Federal Express
Corporation, FedEx Corporation, FedEx Trade Networks Transport &
Brokerage, Inc., FedEx Trade Networks Trade Services, Inc.,
World Tariff, Ltd., FedEx Customer Information Services, Inc.,
and holding company employees only of FedEx Corporate Services,
Inc., FedEx Trade Networks, Inc. and FedEx Freight Corporation.”
J.A. at 414.
16
Amendments or modifications of ERISA plans “must be
implemented in conformity with the formal amendment procedures
and must be in writing.” Coleman v. Nationwide Life Ins. Co.,
969 F.2d 54, 58–59 (4th Cir. 1992). These requirements “are
designed to give both the plan’s participants and administrators
a clear understanding of their rights and obligations, and they
do not authorize oral or implied modifications to a written
plan.” Singer v. Black & Decker Corp., 964 F.2d 1449, 1453–54
(4th Cir. 1992) (Wilkinson, J., concurring) (citations omitted)
(internal quotation marks omitted). Further, these requirements
emphasize the importance of clarity; amendments and
modifications cannot be made cavalierly.
It is not enough for a writing to suggest or imply an
amendment or modification of an ERISA plan; the writing must be
accompanied by a clear intent to amend or modify the plan. See
Biggers v. Wittek Indus. Inc., 4 F.3d 291, 295–96 (4th Cir.
1993); see also Coffin v. Bowater Inc., 501 F.3d 80, 91–92 (1st
Cir. 2007) (“[A]n ERISA plan amendment . . . must clearly alert
the parties that the plan is being amended . . . .”). Specific
language regarding amendment or modification and specific
references to amended or modified sections of a plan, for
example, evidence a clear intent to amend or modify a plan.
See, e.g., Coffin, 501 F.3d at 90; Souza v. R.I. Carpenter’s
17
Pension Plan, No. Civ.A. 05-186S, 2006 WL 2559483, at *5 (D.R.I.
Aug. 31, 2006).
Appellant claims modification was effected in this
case via the minutes from the Board’s meeting on July 14, 2008,
which read as follows:
The [Board] next reviewed a proposal from
the Federal Express Corporation Benefits
Appeals group to outsource remaining long-
term disability appeals effective September
1, 2008, and effectively cease the operation
of the Benefit Review Committee. . . .
Following a thorough discussion, the [Board]
voted to approve the recommendation.
J.A. at 63. However, the Board did not discuss any intent to
modify the Plan; the Board did not mention any portion of the
Plan that was amended; the Board did not mention the Plan at
all. Appellant asks us to find amendment is implied, readily
admitting that the minutes alone would support only modification
by implication. See Oral Argument at 5:00, Bilheimer v. Fed.
Express Corp., No. 13-1859, available at http://coop.ca4.
uscourts.gov/OAarchive/mp3/13-1859-20150326.mp3. We refuse to
allow amendment by implication. See Singer, 964 F.2d at 1453–54
(Wilkinson, J., concurring). 6
6
Appellant asks us to go beyond the Board’s minutes,
imploring us to consider the minutes in conjunction with the
amended service agreement executed by FedEx and Aetna. But the
Plan does not permit the amended service agreement to effect
modification -- the amended agreement is not in the minutes and
was not executed by all of the requisite parties. The only
(Continued)
18
Because the Plan was not actually amended, the
district court correctly determined that Aetna was not given
discretionary authority to review appeals. Accordingly, the
district court applied the proper standard of review, reviewing
Aetna’s decision de novo.
B.
We now address the district court’s conclusion that
Appellee is totally disabled. Under the Plan, an individual who
suffers an “occupational disability” can receive benefits for
two years, whereas an individual who suffers a “total
disability” is not subject to the two-year limitation. The Plan
defines “total disability” as “the complete inability of a
Covered Employee, because of medically-determinable physical or
functional impairment (other than impairment caused by a mental
or nervous condition or a Chemical Dependency), to engage in any
compensable employment for twenty-five hours per week.” J.A.
Sponsoring Employer that was a signatory to the amended
agreement was FedEx. In any event, the impact non-plan
documents -- like the amended agreement -- can have on an ERISA
plan is questionable. See CIGNA Corp. v. Amara, 131 S. Ct.
1866, 1878 (2011) (“[W]e conclude that the summary documents,
important as they are, provide communication with beneficiaries
about the plan, but that their statements do not themselves
constitute the terms of the plan . . . .”); Cosey, 735 F.3d at
170 n.8 (“[I]n the ERISA context, the Supreme Court’s decision
in Amara has cast serious doubt on whether non-plan documents
can be used to interpret a plan’s language.”).
19
414. After reviewing the expert opinions submitted by the
parties and affording greater credit to the experts who actually
treated and examined Appellee, the district court determined
Appellee was totally disabled.
1.
At the outset, Appellant claims the district court’s
interpretation of “compensable employment” was erroneous; we
disagree. The district court refused to narrowly construe this
term, applying the Sixth Circuit’s interpretation of a similar
phrase:
[T]he phrase “prevented from engaging in every
business or occupation” cannot be construed so
narrowly that an individual must be utterly
helpless to be considered disabled and that
nominal employment, such as selling peanuts or
pencils which would yield only a pittance,
does not constitute a “business or
occupation.” Instead, a claimant’s
entitlement to payments based on a claim of
“total disability” must be based on the
claimant’s ability to pursue “gainful
employment in light of all the circumstances.”
VanderKlok v. Provident Life & Accident Ins. Co. Inc., 956 F.2d
610, 614–15 (6th Cir. 1992) (quoting Torix v. Ball Corp., 862
F.2d 1428, 1431 (10th Cir. 1988)).
ERISA is “designed to promote the interests of
employees and their beneficiaries in employee benefits plans,”
so we seek to respect and fulfill the reasonable expectations of
ERISA plan participants. Lown v. Cont’l Cas. Co., 238 F.3d 543,
20
547 (4th Cir. 2001) (internal quotation marks omitted); see
also, e.g., Johnson, 716 F.3d at 820 (“Our
inquiry . . . requires us to consider what a reasonable person
in the position of the participant would have understood those
terms to mean.” (internal quotation marks omitted)).
Reasonable ERISA plan participants would understand
“compensable employment” as meaning “meaningful, gainful
employment”; they would not expect this phrase to mean “any job
at any place with any pay.” The VanderKlok court and the
district court recognized this expectation and sought to avoid
undue economic hardship, furthering the goals of ERISA and
promoting the interests of plan participants. Therefore, we
conclude the district court properly interpreted the scope of
the term “compensable employment.”
2.
Next we review the district court’s factual
determination that Appellee is totally disabled. We review the
district court’s factual findings for clear error. We “will not
reverse a lower court’s finding of fact simply because we would
have decided the case differently.” Easley v. Cromartie, 532
U.S. 234, 242 (2001) (internal quotation marks omitted).
We ask instead whether we are “left with the definite
and firm conviction that a mistake has been committed.” United
States v. Wooden, 693 F.3d 440, 451 (4th Cir. 2012) (internal
21
quotation marks omitted). “If the district court’s account of
the evidence is plausible in light of the record viewed in its
entirety, [we] may not reverse it even though convinced that had
[we] been sitting as the trier of fact, [we] would have weighed
the evidence differently.” Anderson, 470 U.S. at 573–74. We
may also find clear error “when a court makes findings without
properly taking into account substantial evidence to the
contrary.” United States v. Caporale, 701 F.3d 128, 140 (4th
Cir. 2012) (internal quotation marks omitted).
To be entitled to benefits, Appellee must be precluded
from any compensable employment for twenty-five hours per week,
which must be “substantiated by significant objective findings.”
J.A. 406. “[S]ignificant objective findings . . . are defined
as signs which are noted on a test or medical exam and which are
considered significant anatomical, physiological or
psychological abnormalities which can be observed apart from the
individual’s symptoms.” Id. at 406–07. This case turns on
whether Appellee could engage in any compensable employment.
The district court was faced with dueling experts in this
regard.
Although Appellee’s experts were fewer in number, they
had actually examined him: “Dr. Morris conducted a comprehensive
physical examination of [Appellee]” and “Dr. Rougeou treated
[Appellee] at least six times [and] had the opportunity to
22
directly observe [his] physical condition.” J.A. 19. Dr.
Morris noted several limitations on Appellee’s ability to
perform in the workplace, “conclud[ing] that in an eight-hour
workday, [Appellee] could be expected to stand and/or walk for
two hours at most, and to sit for four hours maximum, with a
break every hour.” Id. Based on his observations and
examinations, Dr. Rougeou determined Appellee was totally
disabled:
It is my opinion, based upon my medical
education and experience and based upon my
specific knowledge of [Appellee’s] problems
and treatment history that he is and has
been completely and totally disabled from
performing any employment on a part-time
(twenty-five hours per week) or full-time
basis, consistent with the definition of
disability above. I render my opinion based
upon the cumulative effect of [Appellee’s]
above described objectively diagnosed
medical problems and the subjective symptoms
he suffers.
Id. at 91.
On the other side of the battle of the experts were
several peer review physicians hired by Appellant. Appellant’s
retained experts all agreed Appellee was not totally disabled.
However, none of these experts directly observed Appellee,
conducted a physical examination of Appellee, or contacted
Appellee’s treating physicians.
Tasked with weighing the facts, the district court
discounted the opinions of Appellant’s experts and afforded
23
greater weight to the opinions of Dr. Morris and Dr. Rougeou.
The district court determined that the opinions of Dr. Morris
and Dr. Rougeou deserved more weight because both physicians
“observed [Appellee] in person before opining upon [his] ability
to work.” J.A. 19. The retained experts lacked this hands-on
experience, lessening the persuasive impact of their opinions.
Based on the value ascribed to the various experts, the district
court concluded that “the weight of the evidence indicates that
[Appellee] has the complete inability to engage in any
compensable employment for twenty-five hours per week and is
thus totally disabled.” Id. at 23.
There is no clear error here. The district court’s
account of the evidence is plausible, and nothing indicates the
district court failed to account for substantial evidence to the
contrary. Although a district court cannot require an
administrator to assign certain weight to certain expert
opinions, the district court was entitled to determine the
weight of each expert’s opinion and to afford more weight to the
opinions of treating physicians. Compare Black & Decker
Disability Plan v. Nord, 538 U.S. 822, 834 (2003) (“[C]ourts
have no warrant to require administrators automatically to
accord special weight to the opinions of a claimant’s physician;
nor may courts impose on plan administrators a discrete burden
of explanation when they credit reliable evidence that conflicts
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with a treating physician’s evaluation.”), with Turner v. Ret. &
Benefit Plans Comm. Robert Bosch Corp., 585 F. Supp. 2d 692, 707
(D.S.C. 2007) (finding a court may ascribe greater weight to
opinions of treating physicians based on cumulative review of
the evidence).
Appellant claims the specific limitations outlined by
Dr. Morris belie the district court’s findings. But the
district court discussed these limitations, concluding “that the
limitations articulated by Dr. Morris would preclude [Appellee]
from engaging in any compensable employment for twenty-five
hours per week.” J.A. 23. Although the district court did not
entertain a prolonged discussion of why these findings did not
undermine its conclusion, it cannot be said to have ignored
these limitations. Regardless of how we may view these
limitations, we cannot re-weigh this evidence and usurp the
district court’s role as finder of fact.
Accordingly, we hold that the district court did not
err by determining Appellee fell within the Plan’s definition of
“totally disabled.”
IV.
We conclude that the district court applied the
appropriate standard of review when reviewing Aetna’s denial of
benefits. We further conclude that the district court’s
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decision that Appellee is entitled to benefits under the Plan
was not erroneous.
AFFIRMED
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