Booth v. Wal-Mart Stores

• Decision Date: 27 October 1999
• Docket Number: No. 98-2326,No. 98-2348,WAL-MART,98-2326,98-2348
• Citation: 201 F.3d 335
• Parties: (4th Cir. 2000) BARBARA A. BOOTH, Plaintiff-Appellee, v.STORES, INCORPORATED ASSOCIATES HEALTH AND WELFARE PLAN, sued as Wal-Mart Stores, Incorporated, Defendant-Appellant. BARBARA A. BOOTH, Plaintiff-Appellant, v.STORES, INCORPORATED ASSOCIATES HEALTH AND WELFARE PLAN, sued as Wal-Mart Stores, Incorporated, Defendant-Appellee. . Argued:
• Court: U.S. Court of Appeals — Fourth Circuit

Page 335

201 F.3d 335 (4th Cir. 2000)

BARBARA A. BOOTH, Plaintiff-Appellee, v. WAL-MART STORES, INCORPORATED ASSOCIATES HEALTH AND WELFARE PLAN, sued as Wal-Mart Stores, Incorporated, Defendant-Appellant.

BARBARA A. BOOTH, Plaintiff-Appellant, v. WAL-MART STORES, INCORPORATED ASSOCIATES HEALTH AND WELFARE PLAN, sued as Wal-Mart Stores, Incorporated, Defendant-Appellee.

No. 98-2326.

No. 98-2348.

UNITED STATES COURT OF APPEALS, FOR THE FOURTH CIRCUIT.

Argued: October 27, 1999.

Decided: January 14, 2000.

Appeals from the United States District Court for the Western District of Virginia, at Danville.

Norman K. Moon, District Judge. (CA-96-53-D).

ARGUED: Ashley Bryan Abel, JACKSON, LEWIS, SCHNITZLER & KRUPMAN, Greenville, South Carolina, for Appellant. John Howard Heard, JOHN H. HEARD, P.C., Danville, Virginia, for Appellee. ON BRIEF: Iwana Rademaekers, JACKSON, LEWIS, SCHNITZLER & KRUPMAN, Dallas, Texas, for Appellant.

Before MURNAGHAN, NIEMEYER, and TRAXLER, Circuit Judges.

Reversed by published opinion. Judge Niemeyer wrote the opinion, in which Judge Murnaghan and Judge Traxler joined. Judge Murnaghan wrote a concurring opinion.

OPINION

NIEMEYER, Circuit Judge:

After seeking medical care for chest pain in late November 1994, Barbara A. Booth received a left cardiac catheterization with coronary angiography, followed by a coronary angioplasty to clear a 75% blockage in her right coronary artery. She filed a claim for reimbursement of her expenses under her employee benefit plan, in which she had enrolled four months earlier, but the plan administrator denied the claim under the plan's preexisting condition exclusion.

Claiming that the plan administrator wrongfully denied benefits to which she was entitled, Booth filed this action against the plan under S 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. S 1132(a)(1)(B). The district court concluded, after a bench trial, that the plan administrator had abused its discretion in denying benefits, remanded the matter to the administrator for reconsideration in light of the court's opinion, and granted Booth's motion for attorneys fees.

Because we conclude that the plan administrator could not be found to have abused its contractually conferred discretion in the circumstances of this case, we reverse.

I

Barbara A. Booth, a full-time employee of Wal-Mart Stores, Inc., enrolled in Wal-Mart's self-funded employee benefit plan (the "Plan") on July 29, 1994, when she became eligible to do so. The parties agree that the Plan is governed by ERISA and constitutes an "employee welfare benefit plan" as defined by 29 U.S.C. S 1002(1). Wal-Mart is the sponsor of the Plan but does not act as the Plan trustee. The "administrator" of the Plan, as that term is defined in 29 U.S.C. S 1002(16)(A), is the Plan's Administrative Committee.

In late November 1994, roughly four months after subscribing to the Plan, Booth experienced chest pain, which recurred over the course of five days. Her general physician sent her to be examined by Dr. Boshra G. Zakhary, a cardiologist, who recorded that Booth suffered from hypertension, hypertensive cardiovascular disease, and hyperlipidemia (excess fat in the blood). Because of Booth's chest pain, which was consistent with angina, her multiple risk factors for coronary artery disease, and her abnormal EKG, Zakhary performed a left cardiac catheterization with coronary angiography and left ventriculography on December 2, 1994. Through the procedure (during which a small catheter is inserted into the femoral artery in the groin and threaded up into the arteries in the heart, allowing the cardiologist to shoot dye into the coronary arteries and thereby spot blockages), Zakhary learned that the middle segment of Booth's right coronary artery had a 75% stenosis (blockage), prompting him to recommend that Booth receive a coronary angioplasty (in which a small balloon is inflated within the blockage in order to open the artery). Dr. Victor S. Behar performed a coronary angioplasty to Booth's right coronary artery on December 5, 1994. Upon her discharge, Booth was diagnosed with coronary artery disease with unstable angina, hyperlipidemia, hypertension, and anxiety.

Booth sought reimbursement from the Plan to cover the $30,887.18 in medical expenses that she incurred in relation to the coronary angioplasty procedures. The Plan denied her claim after determining that her condition existed before she enrolled in the Plan or was a secondary condition or complication of a preexisting condition and that her expenses were therefore excluded by the Plan's preexisting condition provision. That provision reads:

Benefits shall not be payable for the following:

Pre-existing conditions.

Any charges with respect to any participant for any illness, injury, or symptom (including secondary conditions and complications) which was medically documented as existing, or for which medical treatment, medical service, prescriptions or other medical expense was incurred within 12 months preceding the effective date of these benefits as to that participant, shall be considered pre-existing and shall not be eligible for benefits under this Medical Coverage, until the participant has been continuously covered under the Medical Coverage 12 consecutive months. (Pre-existing conditions include any diagnosed or undiagnosed condition.)

Booth appealed the denial of her claim, asserting that she had been treated previously for high blood pressure and cholesterol but not for any heart condition. Also, Dr. Julian A. Koplen, Booth's general physician, who provided most of her medical care during the 12-month exclusionary period before her enrollment in the Plan, sent a letter to the Plan stating that he had reviewed Booth's records and found no evidence of preexisting coronary artery disease. He explained that the abbreviation "PVI," which appeared in his treatment records of Booth, denoted "peripheral venous insufficiency" (incompetent veins in legs, resulting in pooling of blood), not "peripheral vascular insufficiency" (insufficient arterial blood supply, resulting in difficulty supplying oxygenated blood to the limbs).

The Plan reviewed its denial of Booth's claims and, as part of its normal appeal process, sought a medical review of its previous determination. The Plan sent Booth's medical records to Dr. William M. Allen, a cardiologist, who was directed to "document any illness, injury or symptom, including secondary conditions and complications" that were related to Booth's diagnoses in November and December 1994 and that had been documented as existing during the 12-month exclusionary period. In summarizing his findings, Dr. Allen related that "[t]he diagnoses of hypertensive heart disease and hyperlipidemia were clearly present" during the exclusionary period. He also stated his belief that Booth had also been treated for coronary artery disease during that period. He noted that, although none of the relevant medical records diagnosed coronary artery disease, Dr. Behar, who performed Booth's coronary angioplasty, had indicated that Booth's coronary artery disease dated back to 1986 when she was evaluated for chest pain.¹ Allen noted that during the exclusionary period Booth was taking Cardizem, a medicine "effective not only for hypertension but also coronary artery disease and angina."

The Plan's Administrative Committee met on August 9, 1995, to consider Booth's appeal and decided to postpone a decision until its next meeting in order to obtain another medical review of the file by a general practitioner, Dr. James H. Arkins. It made this decision because Dr. Koplen was a general practitioner and had disputed the conclusion of Dr. Allen, a cardiologist, that Koplen's records contained evidence of preexisting coronary heart disease or symptoms to suggest the condition.

After reviewing Booth's records, Dr. Arkins reported that he found "numerous pages of documentation of treatment for heart disease and hyperlipidemia" in Booth's medical records from the exclusionary period. He specifically pointed to Dr. Koplen's documentation of Booth's treatment for "HCVD," which Arkins defined as "hypertensive coronary vascular disease," and to Booth's prescription for Cardizem. Dr. Arkins advised the Plan's Administrative Committee, however, that he found no evidence of preexisting hypopotassemia, lung disease, or abnormal blood chemistry.

The Plan's Administrative Committee met again to review Booth's appeal and determined that hypopotassemia, lung disease, and abnormal blood chemistry were not preexisting conditions and that expenses incurred by Booth for their treatment would therefore be reconsidered for payment. But the Plan's Administrative Committee again denied Booth's remaining claims relating to the coronary angioplasty, finding that they were related to preexisting conditions and thus not eligible for coverage.

Booth continued to contest the decision of the Administrative Committee. Dr. Koplen sent a second letter on her behalf to the Committee on October 12, 1995, and reiterated that Booth never had any evidence of coronary disease while she was his patient. He also stated that he believed confusion may have stemmed from a misunderstanding of his abbreviation "HCVD." He stated that, while the Plan's reviewers interpreted HCVD to signify "hypertensive coronary vascular disease," he used the abbreviation to denote "hypertensive cardiovascular disease," a term he asserted physicians use loosely to describe high blood pressure. Also, on March 13, 1996, Booth's attorney sent the Plan a request for another appeal. Thereafter, he forwarded a letter written by Dr. Stephen V. Davis, which stated that Booth was neither treated for nor diagnosed as having coronary artery disease or angina prior to November 1994. Davis' letter also explained that HCVD is a term used by physicians to denote either hypertensive cardiovascular disease...