605 F. App'x 172
4th Cir.2015Background
- FedEx Long Term Disability Plan funds benefits and designates an appeal process overseen by an appeal committee/claims administrator.
- Aetna serves as claims-paying administrator and initially determines eligibility; appeals are handled by an appeal committee appointed by FedEx.
- Appellee Bilheimer sustained injuries in two accidents and became unable to work, leading to continued long-term disability benefits before a later denial.
- Aetna denied further long-term benefits, concluding Bilheimer did not meet the Plan’s total disability definition (unable to engage in 25 hours/week of compensable employment).
- The district court reviewed the denial de novo, found Bilheimer totally disabled, and ordered FedEx to pay benefits; FedEx appeals.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the plan delegates discretionary authority to Aetna. | Bilheimer contends Aetna had discretionary review power. | FedEx argues Aetna may exercise discretion if properly appointed or amended. | Aetna was not given discretionary authority; de novo review applies. |
| Whether the Board actually appointed Aetna as the appeal committee. | Bilheimer asserts appointment via outsourcing and amendments. | FedEx contends outsourcing does not amount to appointment; amendments lacked clear intent. | Plan not amended; Board did not appoint Aetna as the appeal committee. |
| Whether the Plan was effectively amended to vest Aetna with discretion. | Bilheimer relies on minutes or amendments to show modification. | FedEx argues minutes lack clear amendment language; amendments must be explicit. | No valid amendment; Aetna lacked discretionary authority. |
| How to interpret 'appoint' and 'outsource' in the Plan’s appointment of the appeal committee. | Appointment includes a selection/designation process; outsourcing is compatible with appointment. | Outsourcing is not necessarily appointment; terms are ambiguous. | When ambiguous, construe in claimant’s favor; outsourcing does not prove appointment. |
| Whether Bilheimer qualifies as 'totally disabled' under the Plan. | Treating physicians’ opinions show total disability; substantial evidence supports it. | Peer reviews and definitions require ability to engage in compensable employment; not totally disabled. | District court’s de novo determination that Bilheimer is totally disabled is supported by the record. |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (U.S. 1989) (establishes de novo vs discretionary review under ERISA)
- VanderKlok v. Provident Life & Accident Ins. Co., 956 F.2d 610 (6th Cir. 1992) (defines broad interpretation of 'any compensable employment')
- Johnson v. American United Life Ins. Co., 716 F.3d 813 (4th Cir. 2013) (contractual interpretation of plan language and discretion)
- Coleman v. Nationwide Life Ins. Co., 969 F.2d 54 (4th Cir. 1992) (amendment formalities in ERISA plans)
- Singer v. Black & Decker Corp., 964 F.2d 1449 (1st Cir. 1992) (requirement of explicit amendment/ modification language)
- Paese v. Hartford Life & Accident Ins. Co., 449 F.3d 435 (2d Cir. 2006) (standard of review and factual vs legal determinations)
- Nord v. Black & Decker Disability Plan, 538 U.S. 822 (2003) (limits on assigning weight to treating physicians)