Aboul-Fetouh v. Employee Benefits Committee, ABOUL-FETOU

• Decision Date: 16 March 2001
• Docket Number: ABOUL-FETOU,P,No. 00-60367,00-60367
• Citation: 245 F.3d 465
• Parties: (5th Cir. 2001) MOSTAFAlaintiff-Appellant, v. EMPLOYEE BENEFITS COMMITTEE, as Administrator and named Fiduciary of the Group Insurance Plan; THE HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, as the Group Insurance Plan; ENTERGY OPERATIONS, INCORPORATED, a Division of Entergy Corporation, as Fiduciary of the Group Insurance Plan, Defendants-Appellees
• Court: U.S. Court of Appeals — Fifth Circuit

Page 465

245 F.3d 465 (5th Cir. 2001)

MOSTAFA ABOUL-FETOUH, Plaintiff-Appellant, v. EMPLOYEE BENEFITS COMMITTEE, as Administrator and named Fiduciary of the Group Insurance Plan; THE HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, as the Group Insurance Plan; ENTERGY OPERATIONS, INCORPORATED, a Division of Entergy Corporation, as Fiduciary of the Group Insurance Plan, Defendants-Appellees.

No. 00-60367

UNITEED STATES COURT OF APPEALS, Fifth Circuit

March 16, 2001

[Copyrighted Material Omitted] Appeal from the United States District Court for the Southern District of Mississippi

Before REAVLEY, SMITH, and DeMOSS, Circuit Judges.

DeMOSS, Circuit Judge:

This is an ERISA benefits case. Plaintiff-plan beneficiary Mostafa Aboul-Fetouh appeals from the district court's order granting summary judgment in favor of defendant-employer Entergy Operations, Inc. (Entergy), defendant-plan administrator Employee Benefits Committee (EBC), and defendant-claims administrator-insurer The Hartford Life and Accident Insurance Company (Hartford). We affirm.

I.

Between April 1989 and April 1997, Aboul-Fetouh, who has a masters degree in engineering, was employed by Entergy as a technical or senior engineer. In 1990, Entergy Corporation established the Entergy Corporation Companies' Benefits Plus Long Term Disability Plan (the plan). The plan meets the requirements of an employee welfare benefit plan as that term is defined in ERISA. See 29 U.S.C. 1002(1). Entergy funded the plan with a group insurance policy issued by Hartford.

Any review of an ERISA benefit determination must begin with the relevant plan language.¹ The plan provides that it pays disability benefits:

[T]o a Member if, while covered hereunder, the Member (i) becomes Totally Disabled; (ii) remains Totally Disabled throughout the Elimination Period; (iii) remains Totally Disabled beyond the Elimination Period; and (iv) submits proof of loss satisfactory to the Claims Administrator.

The plan defines total disability as follows:

"Totally Disabled" means that during the Elimination Period and for the next 24 months, the Member is prevented by Disability from doing all the material and substantial duties of this own occupation. After that, "Totally Disabled" means that the Member is prevented by such Disability from doing any occupation or work for which he is or could become qualified by training, education, or experience.

The plan defines the elimination period as follows:

"Elimination Period" means the first 6 months of any one period of Total Disability before benefits are payable under this Plan. Notwithstanding any other provision contained herein to the contrary, if a Member ceases to be Totally Disabled and returns to work for a total of 14 or fewer days during an Elimination Period, the Elimination Period shall not be interrupted or extended. Except as otherwise set forth herein, the Member must be Totally Disabled by the same condition for the entire Elimination Period.

Generally, a participant must be disabled by the same condition for the entire elimination period. Moreover, even a series of causally-related disabilities, each lasting less than six months alone, but adding up to an aggregate of six months when combined, will generally not suffice to establish total disability throughout the elimination period. There are, however, at least two exceptions. First, the elimination period will not be interrupted if the participant returns to work during the elimination period for a period of fourteen or fewer days. Second, when the participant suffers from a second period of disability which is (1) caused by the same or a related condition, and (2) begins within three months after the first period of disability terminates, then the second period of disability will be tacked on to the first period of disability and the two periods will be considered a single period of continuous disability under the plan. The plan terms describing this feature provide:

"Period of Disability" means a continuous length of time during which a Member is Disabled under this Plan.

Successive Periods of Disability. If successive Periods of Disability are (i) due to the same cause; or (2) due to a related cause; and (3) separated by 3 months or less; then such successive periods shall be considered one Period of Disability, provided the Plan remains in effect.

When, as here, the participant becomes totally disabled before age 62, the plan potentially provides long term disability benefits for a period of continuous disability until age 65. Benefits terminate earlier, however, upon the occurrence of any of the following circumstances:

(i) the date the Member is no longer Disabled;

(ii) the date on which the Member fails to furnish proof that he is continuously Disabled;

(iii) the date on which the Member refuses to be examined, if the Claims Administrator requires an examination;

(iv) the date on which the Member first receives retirement benefits from a plan provided or sponsored by his Employer; [or]

(v) the date on which the Member dies.

Finally, the plan expressly limits the coverage for conditions "caused, contributed to, or made disabling by" most mental illnesses to a lifetime maximum of twenty-four months. The relevant plan term provides:

Additional Plan Limits. Notwithstanding any other provision contained herein to the contrary, if the Member is Disabled because of: (i) psychosis or neurosis; (ii) any condition caused, contributed to, or made disabling by a psychosis or neurosis; . . . then, subject to all other provisions of this Plan, the Plan shall pay benefits only for so long as the Member is confined in a hospital or other place licensed to provide medical care for such Disability for at least 14 days; or when the Member is not so confined, for a total of 24 months for all such disabilities during his lifetime.

Having set forth the controlling plan terms, we turn to a consideration of the facts relating to Aboul-Fetouh's claim for long term disability benefits.

Aboul-Fetouh was first disabled by a knee injury in August 1993. Aboul-Fetouh filed a claim for long-term disability benefits, which Hartford approved. In March 1994, Aboul-Fetouh's treating physician, Dr. Tiwari, reported that Aboul-Fetouh was no longer totally disabled and that he could return to work at the end of April 1994. Aboul-Fetouh continued receiving benefits until he returned to work on May 2, 1994.

Shortly thereafter, in July 1994, Aboul-Fetouh became disabled by a bout of major depression. Aboul-Fetouh filed a second claim for long term disability benefits on July 15, 1994, which was accompanied by a statement from his psychiatrist, Dr. Coleman. Dr. Coleman stated that Aboul-Fetouh was totally disabled by depression but that Aboul-Fetouh was expected to make a "full recovery" and to return to work on at least a part-time basis in September 1994.

Earlier in July 1994, Aboul-Fetouh was seen by Dr. Tiwari and by another medical provider, Dr. Nordal, Ph.D. Dr. Tiwari recorded that Aboul-Fetouh was being seen for a separate problem, documenting that Aboul-Fetouh was complaining of crying spells, memory loss, depression, and anxiety. Dr. Tiwari conducted clinical studies, including an MRI and EMG studies. The results of these studies were either within normal limits or reported only as minimally significant medical findings. Dr. Nordal likewise concluded that Aboul-Fetouh had difficulty controlling his emotions and making decisions, and that Aboul-Fetouh was suffering from severe anxiety and depression.

Hartford approved Aboul-Fetouh's second claim, but informed Aboul-Fetouh that it was establishing a new elimination period beginning on July 15, 1994, the date of his second disability benefits claim, and ending six months later, on January 14, 1995. Hartford also informed Aboul-Fetouh that it intended to rely upon plan and policy language limiting coverage to a maximum of 24 months when the beneficiary is disabled by some form of mental disability. Hartford subsequently paid long-term disability benefits to Aboul-Fetouh for the 24-month period beginning January 15, 1995 and ending January 14, 1997, and for a short time period thereafter, ending in March 1997.

In the two-year period that Aboul-Fetouh was receiving disability benefits, he was receiving treatment from Dr. Coleman for depression. During at least some of that period, he was also receiving medical treatment from Dr. Tiwari for chronic pain in his neck, chest, and lower back. In January 1996, Aboul-Fetouh also consulted a rheumatologist, who prescribed injections for pain.

When Aboul-Fetouh's entitlement to long-term disability benefits on the basis of his mental disability expired in January 1997, Aboul-Fetouh claimed that he was entitled to continued benefits because he was totally disabled by chronic pain, a condition that would not be subject to the twenty-four month limitation applicable to his claim for depression. Hartford arranged for a functional capacity evaluation to determine whether Aboul-Fetouh was totally disabled by chronic pain. The functional capacity evaluation report stated that Aboul-Fetouh could perform sedentary to light work, as required by his engineering position. The evaluation specifically reported that Aboul-Fetouh was able to lift 15 pounds floor-to-thigh and carry 20 pounds.

After receiving the functional capacity evaluation, Hartford forwarded the report, together with Aboul-Fetouh's file, to a Dr. Silver for an independent medical evaluation. Dr. Silver was charged with deciding whether Aboul-Fetouh was totally disabled by a physical condition that would support the payment of benefits beyond the twenty-four months paid for Aboul-Fetouh's claim based upon depression and anxiety. Dr. Silver concluded that Aboul-Fetouh's depression was severe, but that he was physically capable of returning to the work required by his employment with Entergy. Hartford relied upon the functional...