Vikki A. Wise v. Kind & Knox Gelatin , 429 F.3d 1188 ( 2005 )

United States Court of Appeals
FOR THE EIGHTH CIRCUIT
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No. 05-1130
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Vikki A. Wise, *
*
Appellee, *
*
v. *
*
Kind & Knox Gelatin, Inc., as Plan * Appeal from the United States
Administrator for the Long Term * District Court for the Northern
Disability Benefit Plan of Kind and * District of Iowa.
Knox Gelatin, Inc.; UNUM Life *
Insurance Company of America, as *
Co-Administrator and Underwriter for *
said Plan, *
*
Appellants. *
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Submitted: September 15, 2005
Filed: December 7, 2005
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Before RILEY, HEANEY, and COLLOTON, Circuit Judges.
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RILEY, Circuit Judge.
Vikki A. Wise (Wise) brought this action under the Employee Retirement
Income Security Act (ERISA), 29 U.S.C. §§ 1001-1461, to recover benefits under the
Long Term Disability Benefit Plan (Plan) provided by her employer, Kind & Knox
Gelatin, Inc. (Kind & Knox). UNUM Life Insurance Company of America (UNUM)
was the benefits provider and co-administrator of the Plan with Kind & Knox, the Plan
administrator. The district court held the Plan administrators abused their discretion
in denying Wise’s claim. The Plan and UNUM appeal. We reverse.
I. BACKGROUND
Wise started working as an accounting manager for Kind & Knox on September
8, 1998. On October 8, 1998, after working for Kind & Knox for thirty days, Wise
became eligible for long term disability benefits.
On May 2, 2000, Wise submitted a claim for long term disability benefits,
asserting she was totally disabled due to “Severe pain on left side.” Wise indicated
she first noticed the pain and was treated by a physician for her symptoms on
December 3, 1999. Wise believed her pain was caused by a birth defect resulting in
her arms being three inches shorter than normal between her shoulder and elbow.
Wise’s physician, Dr. John Roberts (Dr. Roberts), completed a physician’s statement
in support of Wise’s claim for long term disability benefits, describing her symptoms
as “Chest wall tenderness – pain left side – ribs & back pain.” His “Objective
Findings” were “Chronic pain syndrome – Intercostal neuritis.”1 Dr. Roberts also
stated Wise’s depression secondarily contributed to her disability.
1
Intercostal neuritis is “[i]nflamation of a nerve . . . [b]etween the ribs.”
Stedman’s Medical Dictionary 910, 1207 (27th ed. 2000).
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The Plan2 limits coverage for a pre-existing condition, defined as “a sickness
or injury for which the insured received medical treatment, consultation, care or
services including diagnostic measures, or had taken prescribed drugs or medicines
in the 6 months prior to the insured’s effective date.” The Plan does not cover pre-
existing conditions unless “the insured completes, after [her] effective date of
coverage, a [treatment-free] period of 12 consecutive months during which [s]he has
not received medical treatment, consultation, care or services including diagnostic
measures, or taken prescribed drugs or medicines.”
UNUM denied Wise’s claim, concluding her conditions were pre-existing and
she received medical treatment for her pre-existing conditions during the treatment-
free period, October 8, 1998, through October 7, 1999. Wise appealed UNUM’s
decision, arguing (1) she had four separate conditions rendering her disabled:
intercostal neuritis, costochondritis,3 chronic pain, and depression; and (2) she did not
receive medical treatment for each condition during the treatment-free period.
UNUM referred Wise’s appeal to an in-house physician, Dr. Maureen Lee
(Dr. Lee), for analysis. Dr. Lee identified two conditions for which Wise filed a claim
for disability benefits: (1) “chronic pain syndrome (intercostal
neuritis/costochondritis),” and (2) depression. Dr. Lee concluded Wise received
2
While Wise worked at Kind & Knox, the Plan was funded by two separate
policies: the 1995 Plan and the 1999 Plan. The district court held the Plan did not
abuse its discretion in concluding Wise had a pre-existing condition and received
treatment for such condition under the 1999 Plan. Wise has not filed a cross appeal
of that determination. Accordingly, the parties agree the issue on appeal is whether
the Plan abused its discretion in concluding Wise had a pre-existing condition and
received treatment for such condition under the 1995 Plan.
3
Costochondritis is defined as “[i]nflammation of one or more costal cartilages,
characterized by local tenderness and pain of the anterior chest wall that may radiate,
but without the local swelling typical of Tietze syndrome.” Stedman’s Medical
Dictionary 418 (27th ed. 2000).
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treatment during the treatment-free period for these two conditions. Based on Dr.
Lee’s report, UNUM denied Wise’s appeal.
Thereafter, Wise contested the denial of coverage by filing suit in the district
court. On judicial review, the district court reviewed UNUM’s denial of benefits for
an abuse of discretion. The district court determined (1) Wise had four separate
conditions–intercostal neuritis, costochondritis, chronic pain, and depression, and
(2) although Wise received treatment for left side pain during the treatment-free
period, there was no evidence suggesting Wise specifically received treatment for
intercostal neuritis. In response to UNUM’s argument that Wise was prescribed
Ultram for intercostal neuritis during the treatment-free period, the district court
stated, “Ultram, a very mild painkiller, obviously is not something that would be used
to treat disabling pain due to inflamed nerves.” The district court thus remanded for
a determination of disability and payment of benefits.
II. DISCUSSION
A deferential standard of review is appropriate under ERISA if “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). The parties agree the district court properly applied an
abuse of discretion standard of review in analyzing UNUM’s disability determination.
See id.
In applying an abuse of discretion standard, “we must affirm if a reasonable
person could have reached a similar decision, given the evidence before him, not that
a reasonable person would have reached that decision.” Ferrari v. Teachers Ins. &
Annuity Ass’n, 278 F.3d 801, 807 (8th Cir. 2002) (quotation omitted). A reasonable
decision is one based on substantial evidence. Norris v. Citibank, N.A. Disability Plan
(501), 308 F.3d 880, 883-84 (8th Cir. 2002). We may consider both the quantity and
quality of evidence before a plan administrator. Id. at 884. We should be hesitant to
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interfere with the administration of an ERISA plan. Id. at 883. We review de novo
the district court’s application of this deferential standard of review. Id. at 884.
Wise concedes her intercostal neuritis, costochondritis, chronic pain, and
depression are pre-existing conditions, and she received treatment for costochondritis,
chronic pain, and depression during the treatment-free period (October 8, 1998,
through October 7, 1999). Wise contends, however, she qualifies for disability
coverage because she did not receive treatment for intercostal neuritis during the
treatment-free period.
The issue before UNUM was whether, between October 8, 1998, and October
7, 1999, Wise “received medical treatment, consultation, care or services, including
diagnostic measures, or [took] prescribed drugs or medicines” for a pre-existing
condition. UNUM concluded Wise received treatment for a pre-existing condition
during the treatment-free period. In reaching that conclusion, UNUM relied on
Dr. Lee’s report indicating Wise had two (not four) pre-existing conditions: chronic
pain syndrome (intercostal neuritis/costocondritis) and depression. UNUM also relied
on Wise’s treating physicians’ notes.
UNUM’s conclusion that Wise received treatment for chronic pain syndrome,
including specifically intercostal neuritis, during the treatment-free period is supported
by substantial evidence. On March 19, 1999, during the treatment-free period, Wise
saw Dr. Roberts “for a check up of multiple medical problems.” Dr. Roberts’s notes
from this office visit mention costochondritis, but not intercostal neuritis. Even
though Dr. Roberts did not diagnose Wise with intercostal neuritis during the March
19 office visit, various doctors, including Dr. Roberts, diagnosed Wise, both before
and after the treatment-free period, as having intercostal neuritis, costochondritis,
chronic pain syndrome, and depression. Given Wise’s office visit with Dr. Roberts
on March 19 “for a check up of multiple medical problems,” UNUM reasonably
concluded Wise received follow-up treatment during the treatment-free period for her
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pre-existing condition of intercostal neuritis. Further, UNUM’s recognition of two,
rather than four, pre-existing conditions, coupling the intercostal neuritis with the
costochondritis in evaluating the “Severe pain on left side,” was not unreasonable.
Additionally, on August 30, 1999, Wise telephoned Dr. Roberts’s office
complaining of left rib pain, and Dr. Roberts advised Wise she could take Ultram for
the left rib pain. The district court’s observation that Dr. Roberts could not possibly
have prescribed Ultram for intercostal neuritis during the treatment-free period,
because “Ultram, a very mild painkiller, obviously is not something that would be
used to treat disabling pain due to inflamed nerves,” is not supported by the record.
No evidence in the record limits or even defines the prescribed uses for Ultram, other
than Dr. Roberts’s express prescription of Ultram for Wise’s left rib pain. We are
unable to find any support in the record for the district court’s factual conclusion
regarding Ultram.
Given our highly deferential standard of review and UNUM’s reasonable
conclusion that Wise sought and received treatment for intercostal neuritis during the
treatment-free period, we will not disturb UNUM’s decision to deny benefits, even if
UNUM could have made a different reasonable decision. Therefore, we hold UNUM
did not abuse its discretion in denying Wise’s claim for long term disability benefits.
III. CONCLUSION
For the foregoing reasons, we reverse the judgment of the district court.
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