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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 Seventh Circuit

Chicago, Illinois  60604

Argued January 13, 2010

Decided July 6, 2010

Before

WILLIAM J. BAUER,  Circuit Judge

DANIEL A. MANION,  Circuit Judge

JOHN DANIEL TINDER,  Circuit Judge

No. 09‐2509

ROBERT WAGNER,

Plaintiff‐Appellant,

v.

ALLIED PILOTS ASSOCIATION

DISABILITY INCOME PLAN,

Defendant‐Appellee.

Appeal from the United States District

Court for the Northern District of

Illinois, Eastern Division.

No. 08 C 2750

Suzanne B. Conlon, Judge.

O R D E R

Robert Wagner was a pilot for American Airlines. For almost ten years he was covered

by a long‐term disability plan offered by the Allied Pilots Association; unfortunately, in 2004

he terminated his policy and in 2005 re‐enrolled.  This meant that he was now subject to all of

the plan’s limitations and exclusions.  Three months after re‐enrolling Wagner ceased flying;

almost a yearlater he applied for benefits, claiming he had a rare inner‐ear disorderthat caused

him to experience dizziness and migraines.   The plan administrator rejected his claim on

NONPRECEDENTIAL DISPOSITION

To be cited only in accordance with

 Fed. R. App. P. 32.1

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No. 09-2509 Page 2

1

 The pertinent language reads as follows: 

(F) Any disability for which the date of Onset of Disability is within six months

following the Effective Date of coverage unless the Disability is due to an injury

that occurs after the Effective Date of coverage. 

several bases, including, and pertinent here, that he was disabled within six months of the

policy’s effective date and the disability was not due to an injury after that date.  Wagner then

filed suit against the Disability Plan (“Plan”) and the district court granted summary judgment

in its favor.  It found that the plan administrator did not abuse its discretion when it refused

to re‐open Wagner’s claim and that it did not abuse its discretion when it denied him coverage

under the plan.  He now appeals. Because the plan administrator offered a reasoned basis,

supported by the record, for denying Wagner’s claim, we affirm.

I.

Robert Wagner was a commercial airline pilot for American Airlines, and beginning in

1996 he was enrolled in the Allied Pilots Association’s disability income plan. For a reason not

reflected in the record he terminated his policy in 2004; the following year he re‐enrolled with

an effectivedate ofApril 1, 2005. By re‐enrolling,Wagner’s participation in theplan was subject

to all the exclusions applicable to new enrollees.  The disability plan excluded coverage for

disabilities that occurred within six months of the enrollment date, unless the disability arose

from an injury occurring after the effective date of coverage.1

For many years, Wagner experienced problems related to his sinuses and ears. And in

1996, he began seeing Dr. Stephen Yeh, an otolaryngologist—better known as an ear, nose, and

throat doctor.    At times the problems were severe, causing Wagner to suffer migraine

headaches,dizziness, and sinusitis.Overthe years,Dr.Yeh prescribed manydifferentmethods

of treatment, including surgery in 1999.

On July 20, 2005, at Wagner’s appointment with Dr. Yeh, they discussed the possibility

of revision surgery to address his persistent problems. Yeh’s notes also reflect that Wagner

complained of “headaches and the effect of flying on his headache and feeling of

disequilibrium with headaches.” The doctor’s notes mention that these may have been

migraines, but he did not diagnose them as such.

The next day, on July 21, Wagner was landing a plane and noticed a problem that he

later described as incapacitating disequilibrium. He assumed it would go away on its own, but

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it didn’t.  Since that day Wagner has not flown a commercial airplane. In August he again saw

Dr. Yeh and again complained of disequilibrium and fullness in his ears. At this time, Wagner

opted for further surgery to address these problems.

Several months after the surgery Wagner consulted another specialist, Dr. Timothy

Hain, who diagnosed him with perilymph fistula, bilateral hydrops, and sinus headaches. The

diagnosis of a perilymph fistula is at the center of this case.  A perilymph fistula is a small

abnormal opening between the air‐filled middle ear and fluid‐filled inner ear. These openings

or tears  are most commonly caused by barotrauma—pressure injuries, which often occur

during scuba diving or following an airplane’s descent during landing.  These tears cause

dizziness, unsteadiness, and a rush of symptoms when there is a pressure change, which can

be as simple as a person blowing his nose.   In other words, a perilymph fistula is debilitating

for any person but especially a pilot.

After seeing Dr. Hain in December 2005, Wagner again saw Dr. Yeh, still complaining

of dizziness.    The notes from that visit indicate that the surgery went well, and Dr. Yeh

regarded Dr. Hain’s diagnosis of perilymph fistula as “unusual.” During a follow‐up visit the

next month, Dr. Yeh noted that Wagner’s sinusitis had improved and that it “was unclear

whether his dizziness is a primary condition or related to his sinusitis or migraines.” He also

noted that “[i]n any case his sinusitis and headache and disequilibrium issues appear to be

environmentally related. [Wagner] connects these symptoms with long airplane flights and

nasal dryness.”

On May 10, 2006, Wagner filed a claim for benefits under the long term disability plan.

He claimed that he was disabled due to “chronic sinusitis, migraines and dizziness.” His claim

was denied.  He then appealed, and in support submitted a letter from Dr. Hain that stated

Wagner’s disability was a perilymph fistula. Because Wagner submitted information on his

appeal suggesting adifferentdisabling condition,theplanadministratortreatedtheperilymph

fistula diagnosis as a second claim, rather than an appeal.  After gathering information from

Wagner and his doctors about the perilymph fistula, the plan administrator denied the second

claim because the disability occurred within six months of the plan’s effective date of coverage

(April 1, 2005) and was not the result of an injury occurring after that date.

Wagner appealed both decisions to the Plan’s Benefits Review and Appeals Board

(“Board”). In support of his appeal, he submitted two letters from Dr. Hain concerning his

perilymph fistula.  Wagner also produced a letter from MetLife rejecting his claim for benefits

under a different disability plan because his injury was work related. After reviewing this

information, the Plan requested medicalrecords fromWagner concerning the date of his injury

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and a list of all the doctors who had treated him for the condition. Wagner stated that he first

noticed the problem on July 21, 2005. The plan administrator also asked Dr. Hain for

clarification of when the perilymph fistula occurred. Dr. Hain responded with Wagner’s

records but nothing that stated or suggested a date of injury.  In his notes, Dr. Hain merely

noted that Wagner has “had ample exposure to pressure changes in the course of [his] career.”

Dr. Yeh also submitted a letter stating that his first notation about perilymph fistula was on

December 13, 2005. Nothing was provided concerning the specific date ofWagner’s injury.  For

the perilymph fistula to be covered, it has to have occurred after the effective date of

coverage—April 1, 2005.

The Plan then submitted Wagner’s appeal and records for review to an independent

medical doctor, Dr. Antonelli. In her report, Dr. Antonelli noted that the documentation

provided did notindicate that a specific traumatic event had occurred. She also discussed what

a difficult diagnosis perilymph fistula is to make and that the records do not show how long

Wagner has had it.  That evaluation was forwarded with the rest of Wagner’s information to

the Board, which denied his appeal.

In the statement of reasons for denying the appeal, the Board stated that “[n]o medical

evidence was presented that conclusively showed the perilymph fistula occurred on July 21,

2005.  In fact, medicalrecords show that you had symptoms consistent with  perilymph fistula

priorto July 2005.” Therefore, itfound that his claim fell underthe exclusion for disabilities that

occurred in the first six months of the policy and was not due to an injury after the effective

date. It was on that basis that they denied his claim.    

Almost a year later, Wagner hired an attorney and sought to re‐open the claim in order

to provide a  response to Dr. Antonelli’s report. Attached to the request was a letter from Dr.

Owen Black rebutting much of what Dr. Antonelli’s report contained and another letter from

Dr. Hain stating: “[m]y opinion is that it is more likely than not that Captain Wagner’s fistula

occurred, in July 2005, rather than in 2001.”

The plan provides a 180‐day window for appeals of a claim’s denial and only materials

received during that time will be considered. The plan also states that “[t]here will be no

exception to this rule.” Citing that language, the plan administrator rejected Wagner’s request

to re‐open his claim. He then sued the Plan under Section 502(a)(1)(B) of the Employee

Retirement Income Security Act of 1974, (“ERISA”) 29 U.S.C. § 1132(a)(1)(B).  

Thedistrict court consideredcross‐motions for summary judgment on whethertheplan

administrator abused its discretion by failing to re‐open the claim and granted summary

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2

 The plan administrator also denied Wagner’s claim because he suffered from a preexisting condition. Wagner also appeals that decision. Because we find that the plan

administrator’s decision to reject his claim for a non-injury disability was not arbitrary and

capricious, we do not need to reach whether the plan administrator abused its discretion in

making its pre-existing condition determination. 

judgment for the Plan, finding that it was not arbitrary and capricious for the plan

administrator to follow the deadlines set forth in the plan’s language. The Plan filed a second

motion for summary judgment on whether the plan administrator’s denial of Wagner’s claim

was arbitrary andcapricious.After considering themotions,thedistrict court grantedsummary

judgment for the Plan, finding that the record supported the denial of Wagner’s claim for

disabilities because his disability occurred within six months of the policy’s effective date and

was not due to injury during that time.2

II.

We review the district court’s grant of summary judgment de novo, meaning we review

the the “plan administrator’s determination directly.”  Jenkins v. Price Waterhouse Long Term

DisabilityPlan, 564 F.3d856, 860 (7th Cir. 2009).  Summary judgmentis appropriate when “there

is no genuine issue as to any material fact and [] the movant is entitled to judgment as a matter

of law.” Fed. R. Civ. P. 56(c).  Where, as here, the plan gives the administrator “discretion  to

determine who is eligible for benefits, we review itsdecision underthe arbitrary and capricious

standard.”    Jenkins, 564 F.3d at 860‐61. Under that standard, we look to ensure that the

administrator’s decision “has rational support in the record.”  Id. at 861 (quotation omitted).

In other words, we will uphold the decision as long as the administrator offers “a reasoned

explanation, based on the evidence, plan documents, and relevant factors that encompass the

important aspects of the problem.”  Fischer v. Liberty Life Assur. Co. of Boston, 576 F.3d 369, 376

(7th Cir. 2009). And when, as here, we review cross‐motions for summary judgment, “we

construe all inferences in favor of the party against whom the motion under consideration is

made.” Speciale v. Blue Cross & Blue Shield Ass’n, 538 F.3d 615, 621 (7th Cir. 2008) (quotation

omitted).

III.    

A.

On appeal, Wagner first argues that the plan administrator should have re‐opened his

claim and reconsidered its decision in light of new evidence.  Eleven months after the plan

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3

 Upholding the Plan’s decision to not re-open the claim has significant consequences for

Wagner’s appeal: the strongest evidence concerning his disability was submitted after the claim

was closed. He submitted a letter from Dr. F. Owen Black that called into question many of the

conclusions Dr. Antonelli made in her report. But we may consider only the “evidence that was

before the administrator in deciding whether her decision passes muster.” Gutta v. Standard

Select Trust Ins. Plans, 530 F.3d 614, 619 (7th Cir. 2008). 

administrator denied the appeal Wagner sought to re‐open the claim and submit additional

material on his disability.    It denied the request, citing the plan’s plain language that

participants must provide any documents, records, or materials to support his claim within

“180 days after the Plan Participant receives notice of the adverse benefit determination.  Any

request for review received by the [Plan]  after this 180‐day period will be null and void.” This

language is echoed elsewhere in the plan, where it states that “only Appeal Materials received

by the [Plan] prior to the end of 180‐day period will be considered.  There will be no exception

to this rule.”

Wehavepreviouslyheldthatinmost cases “unambiguous terms of apensionplanleave

no room forthe exercise ofinterpretivediscretion by theplan’s administrator.”Call v. Ameritech

Mgmt Pension Plan, 475 F.3d 816, 822‐23 (7th Cir. 2007).   The administrator must implement

and follow the plain language of the plan, in so much as they are consistent with the statute.

29 U.S.C. § 1104(a)(1)(D).  This includes a deadline that is consistent with the regulations

governingERISAclaims.  29 C.F.R. § 2560.503‐1(h)(3)(i)(benefitplanmust “[p]rovide claimants

at least 180 days following receipt of a notification of an adverse benefit determination within

which to appeal the determination”).  And by imposing this deadline on Wagner’s appeal, the

plan administrator did not act arbitrarily.    Speciale, 538 F.3d at 623; Tegtmeier v. Midwest

Operating Engineers Pen. Trust Fund, 390 F.3d 1040, 1047 (7th Cir 2004) (applying deadlines is

proper given the plan’s need “for finality of decisions”).  Thus, the plan administrator did not

act arbitrarily and capriciously in enforcing the plan’s clearly established deadlines and

denying Wagner’s request to re‐open the claim.3

B.

Wagner also appeals the plan administrator’s decision to deny him benefits.  Again, our

review of the plan administrator’s decision is extremely deferential: all we require is “a

reasoned explanation, based on the evidence, plan documents, and relevant factors that

encompass the important aspects ofthe problem.”  Fischer, 576 F.3d at 376. The issue of whether

we would have “reached the same conclusion is irrelevant; we will overturn the fiduciary’s

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denial of benefits only if it is completely unreasonable.” Hess v. Reg‐Ellen Machine Tool Corp.,

423 F.3d 653, 659 (7th Cir. 2005) (citation and internal quotations omitted). Wagner argues that

the plan administrator wrongfully denied him benefits because his perilymph fistula was

caused by an injury on July 21, 2005.  Underthe policy a disability that arises within six months

of the policy’s effective date is excluded from coverage, unless it is from an injury that also

occurred after the policy’s effective date.  

Wagner likely has a perilymph fistula and is disabled, even Dr. Antonelli stated as

much. The problem is that it’s unclear when the perilymph fistula occurred and whetherit was

an injury after the effective date of the policy.  The Board’s decision was based on a lack of

evidence submitted by Wagner. To its credit, the plan administrator repeatedly tried to

determine the precise date of Wagner’s injury and specifically requested medicalrecords from

Wagner and his doctors that supplied some evidence of the date of the injury. But nothing was

produced.  Dr. Hain merely stated that Wagner had “ample exposure to pressure changes in

the course of his career.” And even after the plan administrator specifically requested a date

of injury from Dr. Hain, he did not provide one. Dr. Yeh’s records also don’t provide any

evidence of an injury. He was, in fact, indecisive about whether a perilymph fistula was the

precise problem.

The only evidence of an injury occurring is in the brief statements that Wagner

submitted.  In them he states that he felt different during that last flight on July 21, 2005, and

“didn’t know what happened.” In the second statement, Wagner vaguely stated

the first time I noticed this problem was the day I last flew an airplane for

American Airlines (July 21, 2005).  At that time, I had absolutely no idea what

had happened to me to cause this, nor what the exact problem was.  I thought

that perhaps it would go away on its own.  However, this problem never went

away.  It was not until I consulted Dr. Hain that I was told what the cause of my

dizziness was.

Wagner previously described “the problem” as incapacitating disequilibrium.

From the little we can glean from the medical records and reports of perilymph fistula

in the record, it is a severe condition.  It is difficult to diagnose, but its symptoms are dizziness

and headaches.  The symptoms that Wagner said he experienced on that last plane flight are

nondescript: it is also not clear how this disequilibrium was different from the disequilibrium

he experienced and reported to Dr. Yeh the day before his last flight.  There is also nothing in

Dr. Yeh’s notes during the next appointment, three weeks after that flight, that mentions this

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constant, debilitating equilibrium.  And nothing in the records suggests that the headache or

dizziness that he experienced on that last flight were the product of a perilymph fistula injury

during that descent or from a descent months earlier or that the perilymph fistula occurred in

a different manner at some othertime before the plan’s effective date.  In short, there is nothing

in the record to support the conclusion that Wagner had an injury during the first six months

of the policy’s effective date.

It is clear that Wagner had a disability onset during the first six months of the policy’s

effective date.  But the only thing in the record that suggests that Wagner also suffered an

injury during that time is his vague statement about “something different” during the descent

on July 21, 2005. And that statement does not carry sufficient weight to make the plan

administrator’s decision arbitrary and capricious.  Davis, 444 F.3d at 576‐77 (“The judicial task

here is not to determine if the administrator’s decision is correct, but only if it is reasonable.”).

IV.

We find that the Plan did not act arbitrarily and capriciously by denying Wagner’s

request to re‐open his claim after the deadline had passed.  Similarly, given the deferential

standard of review that we apply to these cases and the fact that the plan administrator

considered all of the evidence and arrived at a reasonable conclusion, we find that the plan

administrator did not act arbitrarily and capriciously when it rejected Wagner’s disability

claim.  Accordingly, the judgment of the district court is AFFIRMED.

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