Bilheimer v. Federal Express Corp. Long Term Disability Plan

605 F. App'x 172
CourtCourt of Appeals for the Fourth Circuit
DecidedMay 5, 2015
Docket13-1859
StatusUnpublished
Cited by6 cases

This text of 605 F. App'x 172 (Bilheimer v. Federal Express Corp. Long Term Disability Plan) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fourth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bilheimer v. Federal Express Corp. Long Term Disability Plan, 605 F. App'x 172 (4th Cir. 2015).

Opinion

Affirmed by unpublished PER CURIAM opinion.

Unpublished opinions are not binding precedent in this circuit.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 Appel-lee 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 Appel-lee 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.”

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 (“Aet-na”) 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 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

*175 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.

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 Ap-pellee’s “medical condition [did] not meet the definition of Total 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 [Appel-lee’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 *176 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. 309 (“[TJhere 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.

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Cite This Page — Counsel Stack

Bluebook (online)
605 F. App'x 172, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bilheimer-v-federal-express-corp-long-term-disability-plan-ca4-2015.