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Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 

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United States Court of Appeals

FOR THE EIGHTH CIRCUIT

___________

No. 05-1130

___________

Vikki A. Wise, *

*

Appellee, *

*

v. * 

*

Kind & Knox Gelatin, Inc., as Plan * Appeal from the United States

Administrator for the Long Term * District Court for the Northern

Disability Benefit Plan of Kind and * District of Iowa.

Knox Gelatin, Inc.; UNUM Life *

Insurance Company of America, as *

Co-Administrator and Underwriter for *

said Plan, *

*

 Appellants. *

___________

Submitted: September 15, 2005

Filed: December 7, 2005

___________

Before RILEY, HEANEY, and COLLOTON, Circuit Judges. 

___________

RILEY, Circuit Judge.

Vikki A. Wise (Wise) brought this action under the Employee Retirement

Income Security Act (ERISA), 29 U.S.C. §§ 1001-1461, to recover benefits under the

Long Term Disability Benefit Plan (Plan) provided by her employer, Kind & Knox

Gelatin, Inc. (Kind & Knox). UNUM Life Insurance Company of America (UNUM)

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1

Intercostal neuritis is “[i]nflamation of a nerve . . . [b]etween the ribs.”

Stedman’s Medical Dictionary 910, 1207 (27th ed. 2000).

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was the benefits provider and co-administrator of the Plan with Kind & Knox, the Plan

administrator. The district court held the Plan administrators abused their discretion

in denying Wise’s claim. The Plan and UNUM appeal. We reverse. 

I. BACKGROUND

Wise started working as an accounting manager for Kind & Knox on September

8, 1998. On October 8, 1998, after working for Kind & Knox for thirty days, Wise

became eligible for long term disability benefits. 

On May 2, 2000, Wise submitted a claim for long term disability benefits,

asserting she was totally disabled due to “Severe pain on left side.” Wise indicated

she first noticed the pain and was treated by a physician for her symptoms on

December 3, 1999. Wise believed her pain was caused by a birth defect resulting in

her arms being three inches shorter than normal between her shoulder and elbow.

Wise’s physician, Dr. John Roberts (Dr. Roberts), completed a physician’s statement

in support of Wise’s claim for long term disability benefits, describing her symptoms

as “Chest wall tenderness – pain left side – ribs & back pain.” His “Objective

Findings” were “Chronic pain syndrome – Intercostal neuritis.”1

 Dr. Roberts also

stated Wise’s depression secondarily contributed to her disability.

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2

While Wise worked at Kind & Knox, the Plan was funded by two separate

policies: the 1995 Plan and the 1999 Plan. The district court held the Plan did not

abuse its discretion in concluding Wise had a pre-existing condition and received

treatment for such condition under the 1999 Plan. Wise has not filed a cross appeal

of that determination. Accordingly, the parties agree the issue on appeal is whether

the Plan abused its discretion in concluding Wise had a pre-existing condition and

received treatment for such condition under the 1995 Plan. 

3

Costochondritis is defined as “[i]nflammation of one or more costal cartilages,

characterized by local tenderness and pain of the anterior chest wall that may radiate,

but without the local swelling typical of Tietze syndrome.” Stedman’s Medical

Dictionary 418 (27th ed. 2000). 

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The Plan2

 limits coverage for a pre-existing condition, defined as “a sickness

or injury for which the insured received medical treatment, consultation, care or

services including diagnostic measures, or had taken prescribed drugs or medicines

in the 6 months prior to the insured’s effective date.” The Plan does not cover preexisting conditions unless “the insured completes, after [her] effective date of

coverage, a [treatment-free] period of 12 consecutive months during which [s]he has

not received medical treatment, consultation, care or services including diagnostic

measures, or taken prescribed drugs or medicines.” 

UNUM denied Wise’s claim, concluding her conditions were pre-existing and

she received medical treatment for her pre-existing conditions during the treatmentfree period, October 8, 1998, through October 7, 1999. Wise appealed UNUM’s

decision, arguing (1) she had four separate conditions rendering her disabled:

intercostal neuritis, costochondritis,3

 chronic pain, and depression; and (2) she did not

receive medical treatment for each condition during the treatment-free period. 

UNUM referred Wise’s appeal to an in-house physician, Dr. Maureen Lee

(Dr. Lee), for analysis. Dr. Lee identified two conditions for which Wise filed a claim

for disability benefits: (1) “chronic pain syndrome (intercostal

neuritis/costochondritis),” and (2) depression. Dr. Lee concluded Wise received

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treatment during the treatment-free period for these two conditions. Based on Dr.

Lee’s report, UNUM denied Wise’s appeal. 

Thereafter, Wise contested the denial of coverage by filing suit in the district

court. On judicial review, the district court reviewed UNUM’s denial of benefits for

an abuse of discretion. The district court determined (1) Wise had four separate

conditions–intercostal neuritis, costochondritis, chronic pain, and depression, and

(2) although Wise received treatment for left side pain during the treatment-free

period, there was no evidence suggesting Wise specifically received treatment for

intercostal neuritis. In response to UNUM’s argument that Wise was prescribed

Ultram for intercostal neuritis during the treatment-free period, the district court

stated, “Ultram, a very mild painkiller, obviously is not something that would be used

to treat disabling pain due to inflamed nerves.” The district court thus remanded for

a determination of disability and payment of benefits.

II. DISCUSSION

A deferential standard of review is appropriate under ERISA if “the benefit plan

gives the administrator or fiduciary discretionary authority to determine eligibility for

benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch,

489 U.S. 101, 115 (1989). The parties agree the district court properly applied an

abuse of discretion standard of review in analyzing UNUM’s disability determination.

See id.

In applying an abuse of discretion standard, “we must affirm if a reasonable

person could have reached a similar decision, given the evidence before him, not that

a reasonable person would have reached that decision.” Ferrari v. Teachers Ins. &

Annuity Ass’n, 278 F.3d 801, 807 (8th Cir. 2002) (quotation omitted). A reasonable

decision is one based on substantial evidence. Norris v. Citibank, N.A. Disability Plan

(501), 308 F.3d 880, 883-84 (8th Cir. 2002). We may consider both the quantity and

quality of evidence before a plan administrator. Id. at 884. We should be hesitant to

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interfere with the administration of an ERISA plan. Id. at 883. We review de novo

the district court’s application of this deferential standard of review. Id. at 884.

Wise concedes her intercostal neuritis, costochondritis, chronic pain, and

depression are pre-existing conditions, and she received treatment for costochondritis,

chronic pain, and depression during the treatment-free period (October 8, 1998,

through October 7, 1999). Wise contends, however, she qualifies for disability

coverage because she did not receive treatment for intercostal neuritis during the

treatment-free period. 

The issue before UNUM was whether, between October 8, 1998, and October

7, 1999, Wise “received medical treatment, consultation, care or services, including

diagnostic measures, or [took] prescribed drugs or medicines” for a pre-existing

condition. UNUM concluded Wise received treatment for a pre-existing condition

during the treatment-free period. In reaching that conclusion, UNUM relied on

Dr. Lee’s report indicating Wise had two (not four) pre-existing conditions: chronic

pain syndrome (intercostal neuritis/costocondritis) and depression. UNUM also relied

on Wise’s treating physicians’ notes.

UNUM’s conclusion that Wise received treatment for chronic pain syndrome,

including specifically intercostal neuritis, during the treatment-free period is supported

by substantial evidence. On March 19, 1999, during the treatment-free period, Wise

saw Dr. Roberts “for a check up of multiple medical problems.” Dr. Roberts’s notes

from this office visit mention costochondritis, but not intercostal neuritis. Even

though Dr. Roberts did not diagnose Wise with intercostal neuritis during the March

19 office visit, various doctors, including Dr. Roberts, diagnosed Wise, both before

and after the treatment-free period, as having intercostal neuritis, costochondritis,

chronic pain syndrome, and depression. Given Wise’s office visit with Dr. Roberts

on March 19 “for a check up of multiple medical problems,” UNUM reasonably

concluded Wise received follow-up treatment during the treatment-free period for her

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pre-existing condition of intercostal neuritis. Further, UNUM’s recognition of two,

rather than four, pre-existing conditions, coupling the intercostal neuritis with the

costochondritis in evaluating the “Severe pain on left side,” was not unreasonable.

Additionally, on August 30, 1999, Wise telephoned Dr. Roberts’s office

complaining of left rib pain, and Dr. Roberts advised Wise she could take Ultram for

the left rib pain. The district court’s observation that Dr. Roberts could not possibly

have prescribed Ultram for intercostal neuritis during the treatment-free period,

because “Ultram, a very mild painkiller, obviously is not something that would be

used to treat disabling pain due to inflamed nerves,” is not supported by the record.

No evidence in the record limits or even defines the prescribed uses for Ultram, other

than Dr. Roberts’s express prescription of Ultram for Wise’s left rib pain. We are

unable to find any support in the record for the district court’s factual conclusion

regarding Ultram.

Given our highly deferential standard of review and UNUM’s reasonable

conclusion that Wise sought and received treatment for intercostal neuritis during the

treatment-free period, we will not disturb UNUM’s decision to deny benefits, even if

UNUM could have made a different reasonable decision. Therefore, we hold UNUM

did not abuse its discretion in denying Wise’s claim for long term disability benefits.

III. CONCLUSION

For the foregoing reasons, we reverse the judgment of the district court.

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