Hildebrand v. Fortis Benefits Insurance

70 F. App'x 798
CourtCourt of Appeals for the Sixth Circuit
DecidedJuly 11, 2003
DocketNos. 01-5903, 01-5905
StatusPublished
Cited by3 cases

This text of 70 F. App'x 798 (Hildebrand v. Fortis Benefits Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hildebrand v. Fortis Benefits Insurance, 70 F. App'x 798 (6th Cir. 2003).

Opinion

OPINION

GILMAN, Circuit Judge.

Johnny Hal Campbell appeals the denial of his claim for long-term disability benefits. The claim is based upon his employer’s group disability policy that is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §§ 1001-1461. He contends that his depression is caused by a physiological condition and, as a result, that his disability was improperly categorized by the Fortis Benefits Insurance Company as a “special condition” for which benefits are payable for only 12 months. Fortis, on the other hand, contends that the district court properly found that Campbell’s depression was not primarily caused by his physiological condition. And even if it were, Fortis maintains that the terms of the policy preclude Campbell from receiving benefits beyond the 12-month special-conditions limitation. The district court determined that the Fortis plan administrator’s decision that Campbell is entitled to no further benefits was correct. For the reasons set forth below, we AFFIRM the judgment of the district court.

I. BACKGROUND

Campbell was employed by U.S. Air as a reservation sales agent. In 1990, he became insured under the company’s group long-term disability plan. Campbell filed a disability claim in April of 1995. On his claim form, Campbell stated that he was disabled due to “chronic and major depression due to chemical imbalance.”

Plan benefits are limited for certain “special conditions” to a period of 12 months. “Special conditions” are defined in the plan to mean “mental illness except schizophrenia; dementia; organic brain syndromes; delirium; amnesia syndromes; or organic delusional or hallucinogenic syndromes.” “Mental illness” in turn is defined as “neurosis, psychoneurosis, psychopathy, psychosis, depression, eating and sleeping disorders, or mental or emotional diseases or disorders of any kind including those caused by chemical imbalance. ” (Emphasis added.)

Fortis paid benefits to Campbell for the 12-month special-conditions period. At the end of that time, Campbell claimed that he was entitled to long-term benefits because he was indefinitely disabled. Fortis continued to pay Campbell benefits during the course of his administrative appeals, which lasted until the spring of 1999. Campbell’s arguments have essentially remained the same throughout this process. He suffers from a multitude of physical health problems, including hypothyroidism. Campbell maintains that his hypothyroidism is the cause of his depression. Based upon the alleged ambiguity in the policy language and the circumstances surrounding his depression. Campbell contends that he is eligible for benefits beyond the policy’s 12-month special-conditions limitation.

[800]*800Fortis had Campbell’s file reviewed by numerous doctors and had him independently examined. In addition, both the district court and Fortis took into consideration the opinion of Dr. Judith Akin, Campbell’s treating psychiatrist and the doctor upon whose opinion he principally relies. Fortis determined, based upon all of the medical information received, that Campbell’s disability fell under the special-conditions category.

Upon Campbell’s motion for summary judgment and Fortis’s cross-motion to deny relief, the district court issued a memorandum opinion and order on September 29, 2000, in which it found that Campbell was not entitled to further benefits. The district court construed Campbell’s motion as a motion for entry of judgment, procedurally following this court’s holding in Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609, 619 (6th Cir.1998) (holding that summary judgment was improper for the adjudication of ERISA actions and that district courts should consider the evidence contained in the administrative record and render findings of fact and conclusions of law accordingly). This timely appeal followed.

II. ANALYSIS

A. Standard of review

“We review a district court’s determination regarding the proper standard to apply in its review of a plan administrator’s decision de novo.” Hoover v. Provident Life & Accident Ins. Co., 290 F.3d 801, 807 (6th Cir.2002). The Supreme Court held in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), that an administrator’s decision to deny benefits must be reviewed de novo unless the plan gives the administrator discretionary authority to determine eligibility for benefits. This court held in Perez v. Aetna Life Insurance Co., 150 F.3d 550, 555 (6th Cir.1998) (en banc), that the “arbitrary and capricious” standard of review is utilized in cases where the plan administrator has discretionary authority to determine eligibility for benefits. The plan need not necessarily use the words “discretionary authority” in order to constitute a clear grant of discretion to the plan administrator. Id.

In the present case, the district court held that the language in Fortis’s policy did not grant the plan administrator discretion to decide eligibility for claims. The court therefore reviewed the plan administrator’s decision de novo. Fortis contends that this was error, but that it is not an error that has any bearing on the outcome of this case in light of the district court’s decision on the merits. Campbell does not directly respond to this argument, instead contending that the plan administrator’s decision was arbitrary and capricious. The relevant language in Fortis’s plan reads as follows:

We will pay benefits at the end of each month ... for which we are liable, after we receive the required proof. If any amount is unpaid when disability ends, we will pay it when we receive the required proof.... You must furnish whatever items we decide are necessary as proof of loss or to decide our liability.

We have found no precedent that directly controls the precise language employed in Fortis’s policy. Although we are inclined to believe that the district court erred in holding that the plan administrator lacked discretionary authority under the above-quoted language, we agree with Fortis that it is not necessary for us to definitively decide the question in this case. The district court affirmed the decision of the plan administrator using the more stringent de novo standard of review. Because Campbell’s arguments on appeal offer no persuasive reason for us to reverse the district court’s decision, there is [801]*801no need to further explore the standard-of-review issue.

B. The district court correctly upheld the plan administrator’s determination of Campbell’s disability-benefits claim

Campbell’s arguments break down into three main categories. He argues that (1) the ambiguous terms of the policy should obviate the determination that Campbell qualifies for only short-term disability benefits, (2) this court should weigh the opinion of his treating physician. Dr.

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Bluebook (online)
70 F. App'x 798, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hildebrand-v-fortis-benefits-insurance-ca6-2003.