United States Court of Appeals FOR THE EIGHTH CIRCUIT

_____________ No. 97-2876

_____________ Susan Solger, * * Appellant, * * Appeals from the United States v. * District Court for the * Western District of Arkansas. Wal-Mart Stores, Inc. Associates * Health and Welfare Plan, * * Appellee. *

_____________ No. 97-3752

_____________ Susan Solger, * * Appellee, * * v. * * Wal-Mart Stores, Inc. Associates * Health and Welfare Plan, * * Appellant. *

_____________ Submitted: March 12, 1998 Filed: May 14, 1998

_____________The Ho norable Pasco M. Bowman became Chief Judge of the United State s 1 Court of Appeals for the Eighth Circuit on April 18, 1998. The left and right TMJs connect the jaw to the skull. 2 At oral argument on March 12, 1998, Solger's attorney stated that two weeks 3 before that date Solger had emergency surgery during which the remains of he r implants were removed from her TMJs, ears, and skull. As of oral argument, Solger had not y et undergone the other procedure that is the subject of this litigation: th e insertion of new prosthetic implants into her TMJs. -2- Before FAGG, ROSS, and BOWMAN, Circuit Judges. 1

_____________ BOWMAN, Circuit Judge.
Wal-Mart 's employee health insurance plan imposes a $5,000 cap on coverage of treatment of temporomandibular joint (TMJ) con ditions. Susan Solger, a Wal-Mart 2 employee, asked Wal-Mart to precertify coverage of treat ment for a condition resulting from the partial disintegration of twoTMJ implants she had received before she began working for Wal-Mart. The proposed treatment consisted of surgeryon Solger's TMJs, ears, and skull. This surgery was expected to cost over $50,000. Wal-Mart agreed 3 to pay, but only $5,000; Wal-Mart's pl an administrator determined that the $5,000 cap applied to all of Solger's proposed treatment. Solger appealed

the plan administrator's decision to the District Court pursuant to 29 U.S.C. § 113 2(a)(1)(B) (1994), the section of the Employee Retirement Income Secu rity Act (ERISA), 29 U.S.C. §§ 1001-1461, authorizing civil suits by pla n beneficiaries. The District Court issued two separate orders. First, the court held that the pla n administrator's decision to apply the cap was reasonable with respect t o treatment of Solger's TMJs. Second, the court held that the plan administrator's-3-

decision was unreasonable with respe ct to treatment of Solger's ears and skull. Solger now appeals the first order, and Wal-Mart appeals the second.
Wal-Mart's health insurance plan authorizes the plan administrator to interpret the pro visions of the plan with complete discretion. When an ERISA-governed plan, like this one, acc ords its administrator such discretion, a district court may review the administrator's determinations only for abuse of that discretion. See Cash v. Wal-Mart Group He alth Plan , 107 F.3d 637, 640-41(8th Cir. 1997). The District Court applied the proper standa

rd of review in this case. We review the District Court's application of this standard de novo, see id. at 641; thus, in effect, we review the pla n administra tor's determination for abuse of discretion, just as did the District Court

. Applying this deferential standard of review, we will reverse the plan administrator's interpretation of the plan only if it is unreasonable. We will sustain the administrator's interpretationif it is reasonable, even if it is not the only reasonable interpretation of the plan, and even if we would have chosen a different interpretation had the initia l decision been ours to make. See id.
We t urn first to Solger's appeal, which presents the issue of whether it wa s rea sonable for the plan administrator to apply the $5,000 cap to Solger's propose d surgery on her TMJs. We begin by examining the ex act language of the cap provision. This provision provides that "[t]reatment for the following injury/ illness/ conditions are limited to a lifetime maximum of $5,000 in paid benefits per participant : *Temporo mandibular

joint." Solger v. Wal-Mart Stores, Inc. Assocs. Health & We lfare Plan , Civil No. 97-5075, Mem. Op. at 6 (Sept. 8, 1997) (quoting the plan)

. The critical question

is thus whether the treatment Solger proposed can reasonably be construed as treatment of a conditio n of her TMJs. Solger's proposed surgery entailed removing from her TMJs the remains of the disintegrated implants and reconstructing her TMJs with new implants made of different mater ials. Put simply, these procedures constitute direct treatme nt of Solger's TMJs, the purpose of which is to repair damage in the TMJs. It is difficult to imagine procedures that would more clearly qualify as-4-

treat ment of a condition of the TMJs and therefore be subject to the $5,000 cap. We agree with the District Court that the plan administrator acted reasonably in applying the benefits cap to this treatment.
Next we address Wal-Mar t's appeal. This appeal poses the question whether it was reasonable for the plan administrator to apply the cap to Solger's proposed surgery to re move particles of her disintegrated implants from her ears and skull. The plan adminis trator

determined that this surgery constituted treatment of a condition o f Solger's TMJs, and t

hus was subject to the cap, because the condition in Solger's ears and skull was caused by her TMJ implants. Solger agrees tha t the condition in her ears and skull was caused by her TMJ imp lants , but she argues that the condition therefore was not caused by her TMJs themselves. We see no logical connection, however , between Solger's accurate statement that her TMJ implants caused the condition in her ear s and skull and her assertion that, accordingly, her TMJs did not cause thi s co ndition. The difference between TMJs and TMJ implants does not preclude both from being the cause of the same condition. Solger's TMJ implants were placed inside her TMJs to treat problems in her TMJs by replacing parts of her TM Js: essentially, the im plants served as part of the joints. At the least, a person might reasonably s o conclude. Thus while it is reasonable to say, as Solger does, that her implants caused the condition in her ears and skull, it also is reasonable to say that her TMJs caused that co ndition. We conclude that the plan administrator reasonably deemed the problems in Solger's ears and skull a condition of her TMJs that was subject to the $5,000 cap on benefits. In conclusion, having considered all of Solger's arguments, we hold that the plan adminis trator's application of the $5,000 cap to treatment of Solger's TMJs, ears, and skull was not an abuse o f discretion. We therefore affirm the District Court's order of June 6, 1997, and reverse the District Court's order of September 8, 1997. We need not address Solger's argument that her award of attorney fees is inadequate, becaus e Solger is no longer a prevailing party entitled to an award of attorney fees.-5-

A true copy.
Attest: CLERK, U.S. COURT OF APPEALS, EIGHTH CIRCUIT.