1Judge Luttig heard oral argument in this case but resigned

from the court prior to the time the decision was filed. The

decision is filed by a quorum of the panel pursuant to 28 U.S.C. §

46(d).

UNPUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

No. 05-1255

PAMELA LARUE WILSON,

Plaintiff - Appellant,

versus

METROPOLITAN LIFE INSURANCE COMPANY,

Defendant - Appellee.

Appeal from the United States District Court for the Eastern

District of North Carolina, at Raleigh. Terrence W. Boyle,

District Judge. (CA-01-384)

Argued: March 16, 2006 Decided: May 16, 2006

Before LUTTIG,1

 WILLIAMS, and MICHAEL, Circuit Judges.

Affirmed by unpublished per curiam opinion.

ARGUED: Kenneth M. Johnson, TUGGLE, DUGGINS & MESCHAN, P.A.,

Greensboro, North Carolina, for Appellant. Stephen Alan Dunn,

EMANUEL & DUNN, P.L.L.C., Raleigh, North Carolina, for Appellee.

ON BRIEF: James M. Mason, EMANUEL & DUNN, P.L.L.C., Raleigh, North

Carolina, for Appellee.
2

Unpublished opinions are not binding precedent in this circuit.

See Local Rule 36(c).
2The Employee Retirement and Income Security Act (ERISA)

states that employee benefit plans “shall be established and

maintained pursuant to a written instrument,” 29 U.S.C.A. §

1102(a)(1) (West 1999), and that every participant in an ERISA plan

shall receive a Summary Plan Description (SPD) that is “written in

a manner calculated to be understood by the average plan

participant” and that “apprise[s] [plan] participants . . . of

their rights and obligations under the plan,” 29 U.S.C.A. § 1022

(West 1999). Wilson contends that the Benefits Booklet is not

simply a SPD of the STD and LTD Plans, but that it is the entire

3

PER CURIAM:

Pamela Larue Wilson appeals the district court’s grant of

summary judgment to Metropolitan Life Insurance Company (MetLife)

on her claim for disability benefits. Because MetLife did not

abuse its discretion in determining that Wilson had a preexisting

condition and therefore was not entitled to disability benefits, we

affirm.

I.

On August 12, 1996, Wilson, an Information Systems Specialist,

began working for BDM Federal, Inc. in Raleigh, North Carolina.

Among its benefits, BDM Federal automatically provided Wilson

disability coverage under a Short Term Disability (STD) Plan, and

Wilson also enrolled in the optional Long Term Disability (LTD)

Plan. Both plans were provided through MetLife, which served as

the fiduciary and insurer for the plans. Wilson received a booklet

entitled “BDM: Your Employee Benefits Plan” (the Booklet), which

described both of these plans in separate sections.2 
text of those plans and that there is not another, more complete

document serving as the official plan upon which MetLife’s decision

was based. MetLife does not dispute Wilson’s contention, and we

therefore assume Wilson is correct. See, e.g., Alday v. Container

Corp. of Am., 906 F.2d 660, 662 n.2 (11th Cir. 1990) (noting that

the formal ERISA plan and the SPD at issue in that case were

identical). 

4

An employee became eligible for benefits under each Plan on

different dates. Under the STD Plan, Wilson became eligible for

benefits on the date that she began working for BDM Federal –-

August 12, 1996. The LTD Plan delayed an employee’s eligibility

for benefits until she had completed six months of continuous

employment with BDM Federal, so Wilson did not become eligible for

LTD benefits until February 12, 1997.

The LTD Plan also included a Pre-existing Condition

Limitation, which stated

This Plan does not provide benefits for any Disability

that is caused by, contributed to by, or resulting from

a Pre-Existing Condition, unless the Disability begins

after you have been covered under This Plan for 12 months

in a row.

(J.A. at 600.) In Wilson’s Booklet, a definition of “Pre-Existing

Condition” was not included in the LTD Plan. The STD Plan,

however, did include a definition of “Pre-Existing Condition” even

though the STD Plan did not have a Pre-Existing Condition

Limitation. On page 9 of Wilson’s STD Plan, “Pre-Existing

Condition” was defined as

[A] Sickness or Injury for which [an employee] received

Medical Advice or Treatment during the 3 month period
3The STD Plan and LTD Plan sections had separate Tables of

Contents, but the contents on pages 9 and 10 of each Plan did not

correspond with the respective Table of Contents. For example,

according to the Table of Contents for the STD Plan in Wilson’s

Booklet, page 9 should include “Provisions Applicable to Pregnancy”

and “When Benefits End,” but those provisions are found on page 9

of Wilson’s LTD Plan. Similarly, the Table of Contents for the LTD

Plan indicates that pages 7-15 should explain the details of “Long

Term Disability Benefits,” but those pages are interrupted by the

pregnancy provisions on page 9 and a statement on page 10 of when

short term disability benefits end -- terms clearly not germane to

the LTD Plan.

4BDM Federal, the LTD Plan’s official Plan Administrator,

shared this authority. 

5

immediately prior to [the employee’s] effective date of

Personal Benefits.

(J.A. at 586.) 

As became evident later, the reason the STD Plan had a

definition of “Pre-Existing Condition” was because Wilson’s Booklet

was flawed; pages 9 and 10 of the STD Plan and pages 9 and 10 of

the LTD Plan were apparently swapped.3 

The LTD Plan reserved to MetLife the discretionary authority

“to interpret the terms of the Plan and to determine eligibility

for and entitlement to Plan benefits in accordance with the terms

of the Plan.” (J.A. at 605.) MetLife therefore possessed the

authority to manage the administration of benefits under the LTD

Plan.4

On January 22, 1997, approximately five months after she began

working at BDM Federal, Wilson was evaluated at the Duke University

Medical Center’s Orthopaedic Clinic for heel spurs and pain in her
6

left shoulder. According to the Clinic’s notes, Wilson began

experiencing shoulder pain after she fell down approximately ten

stairs a year-and-a-half before visiting the Clinic. At the

Clinic’s recommendation, Wilson was further evaluated for

polyarthralgias, or joint pain, on January 29, 1997, by Dr. N.M.

Kredich, in Duke’s Rheumatology Clinic. Dr. Kredich could not

diagnose the medical cause for Wilson’s joint pain, although he did

rule out rheumatoid arthritis. Dr. Kredich also noted that

Wilson’s problems began after her fall. Two days later, on January

31, Wilson sought medical care at the Womac Army Medical Center for

her persistent pain.

Because her joint pain did not abate after these medical

evaluations, on June 10, 1997, Wilson stopped working at BDM

Federal. A month later, she began receiving short term disability

benefits. On July 15, 1997, MetLife received a Disability Claims

Report that Wilson had stopped working because of “pain in [her]

joints.” (J.A. at 559.) On May 20, 1998, MetLife approved

Wilson’s claim for long term disability benefits and made those

benefits retroactive to the expiration of her short term disability

benefits. In April 1999, MetLife requested updated medical

information from Wilson, which she provided. Although Wilson

submitted no new relevant information relating to her eligibility

for benefits, MetLife reviewed Wilson’s file and realized from

available information that her disability was caused by a condition
7

-- joint pain -- for which she had received medical advice or

treatment within the three months preceding her eligibility date

for LTD Plan benefits. As a result of this review, MetLife wrote

Wilson on July 19, 1999, and referred her to the “Pre-Existing

Condition Limitation” and to the definition of “Pre-Existing

Condition” contained within the LTD Plan. (J.A. at 142-43.)

Noting that Wilson was treated on January 29 and 31, 1997, for

joint pain, MetLife informed Wilson that it had determined that her

disability claim fell within the LTD Plan’s “Pre-Existing Condition

Limitation” and that it was terminating her benefits. 

Wilson then brought this action under the Employee Retirement

Income Security Act (ERISA), 29 U.S.C.A. § 1132 (West 1999), to

have her LTD Benefits reinstated. MetLife moved for summary

judgment, submitting the entire administrative record for Wilson’s

LTD claim, including an original Booklet.

In her response in opposition to MetLife’s motion, Wilson

submitted a copy of her Booklet and noted that it did not include

the definition of “Pre-Existing Condition” within the LTD Plan

section, unlike MetLife’s Booklet. Because Wilson’s Booklet

contained all the information available to her about MetLife’s

disability plan, the district court analyzed MetLife’s decision to

terminate benefits under the terms of her Booklet. Analyzing the

Booklet as setting forth one plan with two sections, the district

court noted that although the LTD Plan section did not include a
5Although MetLife filed a counterclaim to recover the

$35,459.50 that had been paid to Wilson as LTD benefits, the

district court entered judgment in favor of Wilson on MetLife’s

counterclaim, and MetLife does not appeal that decision. 

8

definition of “Pre-Existing Condition,” “the fact that the

definition was contained in a previous section of [Wilson’s] Plan

does not mean that it is inapplicable to other sections of the

Plan[] as well.” (J.A. at 614.) Accordingly, the district court

concluded that “the definition of ‘Pre-Existing Condition’

contained in the Short-Term Benefits Section of the Plan is equally

applicable to give meaning to the term[] ‘Pre-Existing Condition,’

as used in the Pre-Existing Condition Clause” in the LTD Plan.

(J.A. at 614.) As such, the district court concluded that MetLife

correctly applied the LTD Plan’s pre-existing condition limitation

to Wilson’s claim for benefits. Wilson timely noted an appeal.5

II.

We review de novo the district court’s decision granting

summary judgment to MetLife, “applying the same standards that the

district court employed.” Evans v. Metropolitan Life Ins. Co., 358

F.3d 307, 310 (4th Cir. 2004). The LTD Plan gives MetLife

“discretionary authority . . . to determine eligibility for and

entitlement to [LTD] Plan benefits” (J.A. at 605); however,

MetLife’s capacity as the insurer of the LTD Plan creates a

conflict of interest. Evans, 358 F.3d at 311. We therefore review
6Wilson supports her argument that the Booklet comprises two

distinct and self-contained plans by pointing to the fact that the

STD Plan and LTD Plan sections of the Booklet each possessed the

accouterments of a distinct SPD. Her argument before us, however,

contradicts what she argued to the district court. See Resp. in

Opp’n to Def.’s Mot. Summ. J., Wilson v. Metropolitan Life Ins.

Co., No. 5:01-CV-384 (E.D.N.C. 2002) (“[Wilson] . . . was issued an

SPD covering both the STD Plan and the LTD Plan . . . .” (emphases

added)). Nevertheless, we need not address whether the Booklet

included one unitary Plan or two distinct Plans, because the proper

mode of analysis is to compare Wilson’s flawed Booklet with

MetLife’s accurate Booklet to determine if there is a conflict

between the two Booklets and if Wilson relied on, or was prejudiced

by, her Booklet.

9

MetLife’s denial of benefits under a modified abuse of discretion

standard, in which we consider MetLife’s conflict in determining

whether MetLife abused its discretion in denying benefits to

Wilson. Id. The touchstone for properly-exercised discretion is

whether a plan administrator reached a reasonable decision after a

deliberate and principled reasoning process and whether that

decision is supported by substantial evidence. Id.

 

A.

Wilson contends that the district court erred in treating the

Booklet as a unitary document and concluding that the definition of

“Pre-Existing Condition” found in the STD section applied to the

LTD section. She argues that the Booklet comprises two distinct

plans -- the STD Plan and the LTD Plan -- and that therefore it is

improper to import the STD Plan’s definition of “Pre-Existing

Condition” into the LTD Plan.6 Assuming that Wilson is correct
10

that the Booklet comprises two separate and distinct Plans, we

nevertheless conclude that MetLife did not abuse its discretion in

terminating her benefits because MetLife properly based its

decision on the terms of the LTD Plan as found in the accurate

Booklet.

B. 

 As described above, Wilson received a flawed Booklet, and

MetLife based its decision to terminate Wilson’s disability

benefits on its LTD Plan, which contained the definition of “PreExisting Condition.” We first examine whether MetLife abused its

discretion in applying the definition of “Pre-Existing Condition”

contained in its LTD Plan when Wilson’s LTD Plan did not contain

that definition.

Wilson’s flawed version of the LTD Plan would control over

MetLife’s accurate version if there was a conflict between the two

and Wilson relied on, or was prejudiced by, her version. Hendricks

v. Cent. Reserve Life Ins. Co., 39 F.3d 507, 511 (4th Cir. 1994).

If there is no conflict between the documents, we need not analyze

reliance or prejudice. Martin v. Blue Cross & Blue Shield of

Virginia, 115 F.3 1201, 1204 (4th Cir. 1997). To determine whether

Wilson’s LTD Plan conflicts with MetLife’s Plan, we examine whether

“the generally accepted definition[]” of “Pre-Existing Condition”

“differ[s] substantially from the definition[] of th[at] term[]
11

given in” MetLife’s LTD Plan. Hendricks, 39 F.3d at 512. 

According to generally accepted definitions, “pre-exist” means

“to exist previously or before (another person or thing),” and

“condition” means “[a] state of health” or “an illness [or]

ailment.” Webster’s New World Collegiate Dictionary 290, 1062 (3d

ed. 1997). Therefore, “Pre-Existing Condition” is commonly

understood simply as an illness or ailment that existed before a

certain time. Although MetLife’s LTD Plan has a more precise

definition of “Pre-Existing Condition,” it is “not so different

from [the] common understanding[] of the term[] that [it] can be

thought to conflict with t[hat] understanding.” Hendricks, 39 F.3d

at 512 (emphasis added). 

Moreover, Wilson cannot show reliance on her version of the

Booklet or prejudice from MetLife’s application of its definition

of “Pre-Existing Condition.” First, the definition applied by

MetLife is actually more favorable to Wilson because it limits

“condition” to a sickness or injury for which medical advice or

treatment was obtained and “pre-existing” to a three month period

of time before she became eligible for LTD Plan benefits. The

generally accepted definition of “Pre-Existing Condition” is not

that limited and would include any illness -- treated or untreated

-- that existed at any time prior to a particular temporal
7Wilson proposes that “Pre-Existing Condition” should mean a

condition “for which [she] sought medical advice, care or treatment

during the period prior to her employment with BDM [Federal].”

(Appellant’s Br. at 25.) As discussed, however, the generally

accepted definition of “Pre-Existing Condition” includes all

illnesses or ailments, regardless of whether medical treatment was

sought. The effect of Wilson’s proposed definition is that she

gets to keep the portion of the LTD Plan’s definition that benefits

her -- the more limited definition of “condition” -- while

jettisoning the portion that does not -- the point of measurement

for “pre-existing.” We therefore reject her proposed definition

because it is not the same as the generally accepted definition of

“Pre-Existing Condition.” 

12

reference point.7 Second, applying the generally accepted

definition, we still would have to identify a temporal reference

point for determining whether a medical condition is pre-existing.

In Wilson’s case, there are two logical temporal reference points:

pre-existing could refer –- as Wilson contends –- to the time

before she enrolled in the LTD Plan in August 1996, or it could

refer to the time before she became eligible for LTD benefits. But

from either reference point, Wilson’s condition was pre-existing

because her medical records indicate that her ailment -- the joint

pain for which she sought treatment at Duke in January 1997 –-

began a year earlier following her fall down stairs. 

Because Wilson’s version of the Booklet is not in conflict

with MetLife’s, and, in any event, because Wilson cannot show that

she relied on, or was prejudiced by, her version of the Booklet,

MetLife did not abuse its discretion by applying the correct
13

version of the LTD Plan and accompanying definition of “PreExisting Condition.” 

 

C.

Wilson also contends that MetLife abused its discretion by

terminating her benefits based on the same medical information that

was available at the time of its initial decision to grant her

benefits. Relying on one of the criteria for reasonableness that

we articulated in Booth v. Wal-Mart Stores, Inc., 201 F.3d 335, 342

(4th Cir. 2000), Wilson contends that MetLife did not consistently

interpret the provisions of the LTD Plan because it first concluded

that she did not have a pre-existing condition but then later

determined that she did. 

We do not believe that MetLife inconsistently interpreted the

LTD Plan. Nothing in the record before us suggests that MetLife

has previously interpreted “Pre-Existing Condition” to mean

something other than “a Sickness or Injury for which [the employee]

received Medical . . . Treatment” during the three-month period

preceding an employees’s eligibility date for benefits. (J.A. at

115.) Instead, MetLife initially failed to apply the “Pre-Existing

Condition Limitation” to Wilson’s claim for LTD benefits, but it is

not estopped from enforcing that provision of the LTD Plan simply

because of its initial failure to do so. See Coleman v. Nationwide

Life Ins. Co., 969 F.2d 54, 60 (4th Cir. 1992) (holding that
14

estoppel principles do not bind a plan administrator to prior

representations of coverage). Although it is certainly preferable

that a plan administrator reach in the first instance a correct

decision to grant or deny benefits, we do not believe that a plan

administrator abuses its discretion by terminating benefits after

a review of available information shows that the initial grant of

benefits was contrary to the terms of the plan. See Ellis v.

Liberty Life Assurance Co., 394 F.3d 262, 274 (5th Cir. 2005)

(holding that a plan fiduciary does not need to meet a higher

standard of proof to terminate benefits once granted than is needed

to sustain a denial of benefits in the first instance), cert.

denied, 125 S. Ct. 2941 (2005). Otherwise, plan administrators

would be severely constrained from terminating benefits that were

erroneously granted, resulting in plan administrators becoming more

hesitant about initially granting benefits lest they be stuck with

a wrong decision. Id. (noting the “chilling effect” of requiring

a heightened standard of proof to terminate erroneously-granted

benefits). We therefore conclude that MetLife did not abuse its

discretion in correcting its application of the LTD Plan to

Wilson’s claim and terminating her LTD benefits. 

III.

We conclude that MetLife did not abuse its discretion in

determining that Wilson’s disability fell within the pre-existing
15

condition limitation of the LTD Plan and that MetLife did not abuse

its discretion in terminating her benefits after it initially

granted them. We therefore affirm the district court’s grant of

summary judgment to MetLife.

AFFIRMED