West v. Paul Revere Life

NOT RECOMMENDED FOR FULL-TEXT PUBLICATION
File Name: 05a0562n.06
Filed: July 6, 2005

No. 04-3507

UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT

R. CHRISTOPHER WEST, )
) ON APPEAL FROM THE
Plaintiff-Appellant, ) UNITED STATES DISTRICT
) COURT FOR THE SOUTHERN
v. ) DISTRICT OF OHIO
)
THE PAUL REVERE LIFE INSURANCE ) OPINION
COMPANY, )
)
Defendant-Appellee. )

BEFORE: COLE and SUTTON, Circuit Judges; ZATKOFF, District Judge*

R. GUY COLE, JR., Circuit Judge. Plaintiff-Appellant R. Christopher West appeals the

district court’s order adopting the magistrate judge’s recommendation to affirm Defendant-Appellee

Paul Revere Life’s (“Revere Life”) denial of disability benefits. The district court held that Revere

Life’s denial of benefits was not arbitrary and capricious because the administrator appropriately

construed the plan to disqualify West because West did not show that he had a sickness that

manifested itself after the date of issue of his policy and because he did not show that he was unable

to perform the important duties of his occupation as hospital administrator. Because the plan

administrator’s determination was neither arbitrary nor capricious, we AFFIRM on the grounds that

*
The Honorable Lawrence P. Zatkoff, United States District Judge for the Eastern District
of Michigan, sitting by designation.
No. 04-3507
West v. Paul Revere Life

West did not show that he had a sickness that manifested itself as required by the language of the

policy.

I. BACKGROUND

Plaintiff-Appellant, R. Christopher West, was employed as the senior vice-president for

hospital services by Norton Healthcare, Inc., from May 1999 through February 2000. Prior to such

employment, West worked as an administrator for various health care organizations for

approximately eighteen years.

While at Norton, West exhibited difficulties with written and spoken communication. Upon

Norton’s request, West underwent extensive diagnostic testing at the Mayo Clinic medical facility.

Mayo Clinic physicians diagnosed West with Expressive Language Disorder, Reading Disorder, and

Disorder of Written Expression. The examining physician noted that West would need “extensive

complementary accommodations and administrative assistance in written and oral communication

duties, that ultimately would result in significant revision of the job description.” Based on this

diagnosis and West’s examining physician’s statement indicating West would require “extensive

complementary accommodations and administrative assistance in written and oral communication

duties, that ultimately would result in significant revision of the job description,” Norton concluded

that West would be unable to perform the necessary and essential job functions, and terminated him.

Following his termination, West filed a claim for disability benefits under an insurance

policy covering Norton employees. The administrator of the policy denied West’s claim, issuing

a letter explaining the denial, as well as West’s appeal rights. According to the letter, West’s claim

was denied because the company determined that his sickness was a “life long disorder[]” rather

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West v. Paul Revere Life

than one that arose during the time of his coverage. In addition, the letter indicated that benefits

were not appropriate because West was not totally disabled as he could still perform the duties of

his “occupation” as a hospital administrator with the appropriate accommodations.

West appealed the denial of his claim through Revere Life’s administrative appeals’ process.

The insurance company upheld its initial denial of benefits, explaining that West was not eligible

for coverage because: (1) his condition did not constitute a “sickness” for purposes of the insurance

policy due to the fact that his condition was a “lifelong problem,” (2) he was not totally disabled

because he could perform the important duties of his occupation with accommodation, (3) he was

never able to perform the duties required by Norton Healthcare, and (4) Revere Life’s

neuropsychologist did not believe West was “totally incapable of performing his essential

occupational functions.”

West filed the present appeal in district court pursuant to § 502(d)(1) of the Employee

Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(d)(1). On recommendation of the

magistrate judge, the district court held that Revere Life’s denial of benefits was not arbitrary and

capricious because West did not show that he had a sickness that manifested itself after coverage

or that he was unable to perform the important duties of his occupation as hospital administrator.

The court therefore denied West’s motion to reverse the administrator’s decision, entered judgment

in favor of Revere Life, and dismissed the case. This appeal followed.

II. ANALYSIS

A. Standard of Review

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West v. Paul Revere Life

We review the district court’s judgment in an ERISA case de novo. Killian v. Healthsource

Provident Admin’rs, Inc., 152 F.3d 514, 520 (6th Cir. 1998). Ordinarily, the district court reviews

an administrator’s decision to deny insurance benefits de novo. Jones v. Metro. Life Ins. Co., 385

F.3d 654, 659-60 (6th Cir. 2004). However, where the administrator has discretion to determine

eligibility for benefits or to construe the plan terms, the district court reviews the decision using the

arbitrary and capricious standard. Killian, 152 F.3d at 520.

West argues that the district court erred in applying the arbitrary and capricious standard

rather than the de novo standard because the terms of the plan did not indicate “to whom satisfactory

proof of loss should be given” and consequently were insufficient to confer discretion on the plan

administrator. The terms of the contract must indicate to whom proof of loss should be given in

order to grant discretion to the plan administrator. Perez v. Aetna Life Ins. Co., 150 F.3d 550, 555-

56 (6th Cir. 1998) (en banc). The plan terms state that benefits will be granted “[a]fter we receive

satisfactory proof of loss.” The term “we” is sufficient to indicate that it is the insurance company

that must receive satisfactory proof of loss. Cf. Yeager v. Reliance Standard Life Ins. Co., 88 F.3d

376, 380-81 (6th Cir. 1996) (holding requirement that claimant submit satisfactory proof of loss “to

us” sufficient to confer discretion to plan administrator). The language is therefore sufficient to

confer discretion to the plan administrator, and the arbitrary and capricious standard is thus

appropriate in this case.

West also argues that the plan administrator had a conflict of interest, which must be taken

into account when reviewing Revere Life’s denial of benefits. There is an inherent conflict of

interest when a plan administrator determines whether an individual qualifies for insurance benefits.

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West v. Paul Revere Life

Killian, 152 F.3d at 521. As noted by the district court, this conflict does not alter the standard of

review, but it is a factor this Court considers in determining whether the administrator’s actions were

arbitrary and capricious. Id.

B. Did West’s condition constitute a “sickness” under the insurance policy?

Although West’s learning disorder constituted a sickness under the policy, West is not

entitled to disability benefits because the disorder manifested itself prior to the date on which the

policy covered West. The policy defines sickness as a condition that “first manifests” after the

policy is issued. West argues that his condition did not manifest itself prior to the date of issue of

his policy because the sickness had not yet been diagnosed. Revere Life counters this argument,

claiming that the condition had manifested itself prior to coverage because West displayed signs and

symptoms of the condition and had taken steps to compensate for it. The question for this Court,

therefore, is whether the plain meaning of the word “manifests” is consistent with Revere Life’s

interpretation in this context to mean displaying signs or symptoms of a disease rather than obtaining

a specific diagnosis of a disease.

When interpreting the terms of an insurance plan, the administrator must interpret words

according to their plain meaning. Perez, 150 F.3d at 556. Merriam Webster’s Collegiate Dictionary

defines manifest as “to make evident or certain by showing or displaying.” Merriam Webster’s

Collegiate Dictionary 707 (10th ed. 1993). Consistent with this definition, Revere Life determined

that a condition “manifests” itself when it is evident due to apparent signs or symptoms of that

condition. To hold that a condition only manifests itself upon diagnosis runs contrary to the plain

meaning of the word “manifests.” A disorder becomes evident when there are significant signs and

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West v. Paul Revere Life

symptoms of the sickness, not when it is officially diagnosed by a medical professional. As such,

the administrator appropriately found that West’s condition manifested itself prior to coverage since

West displayed signs and symptoms of the disease prior to such time. Cf. Black’s Law Dictionary

974 (7th ed. 1999) (defining “manifestation theory” for insurance purposes as “[t]he doctrine that

coverage for an injury or disease falls to the policy in effect when the symptoms of the covered

injury or disease first appear.”). West told his physician that he has always had difficulty

pronouncing certain words, that his vocabulary is somewhat limited, that he had trouble spelling

words when he was in school, and that he had been compensating for his difficulties with words and

language his entire life. In addition, West never challenged the claim representative’s description

of a phone call in which he admitted that in 1991 and 1992 “he knew that he had a problem [and]

he worked [with a] speech therapist to overcome difficulties.” Because West sought speech therapy

in 1991 and 1992, he obviously knew that he had a speech problem before signing the application

for coverage on October 14, 1992. Accordingly, the plan administrator’s determination that West’s

disorder was a lifelong condition rather than one that manifested itself after coverage was not

arbitrary and capricious, and denial of benefits on this basis was not error.

C. Was West “unable to perform the important duties” of his occupation for purposes of the
insurance policy?

Revere also denied West coverage based on its determination that West could still perform

the important duties of his occupation with accommodation. West argues that this interpretation of

the contract inappropriately added an accommodation requirement to the terms. We need not reach

this issue today, as the administrator’s determination that West did not qualify for benefits because

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West v. Paul Revere Life

his condition had manifested itself prior to coverage was not arbitrary and capricious and provides

an adequate basis upon which to affirm the district court’s judgment.

III. CONCLUSION

Because the plan administrator’s determination that West was ineligible for coverage because

he did not have a condition that manifested itself after plan coverage was not arbitrary and

capricious, we AFFIRM the judgment of the district court.

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