The Honor able John D. Holschuh, United States District J udg e for the Southern District of * Ohio, sitti ng by

desig nation. NO T R EC OM M EN DE D F OR F UL L- TEX T P UB LIC AT ION File Na me: 09a0717n.06 No. 08-4033

UN ITED STA TES C OU RT OF AP P EA LS F OR THE SI XT H C IR CU IT RUTH A. MITZEL, P laintif f-App ellee,

v. ANTHEM LIFE INSURAN CE CO., et al., De fend ant s- App e lla nt s. / ON AP P EA L F RO M THE U NI TED STA TES D ISTRIC T C OU RT F OR THE NO RT HER

N D ISTRIC T OF OHI O

BEFORE: CLAY and Mc KEAG UE, Circuit Judges; and HOLS CHUH, District Judge. * CLAY, Circ uit Jud ge. Def endants Anthem L ife I nsuranc e Compan y (“ An t hem”) , Wellpoint , I nc. (“Wellpoint”) and Wellpoint Flexible B enef it Plan appea l the district court’s orde r

reve rsing Def

endants’ de nial of long -term disabilit y b en ef i ts for Plaintiff Ruth Mit zel (“Mitzel”). Mitz el brought t his enfor ceme nt action pursua nt to the Employ ee Re tirement Income Sec urity Act of 1974 (“ERI SA”), 29 U.S.C. § 1001 et seq. , af te r the he a lth pla

n a dmi nis tr a tor

de nie d h e r c la im for long -term disability benef its. On appea l, D efe ndants argue that the district c ourt err ed in finding that the administrator’s de cision had been arbitra ry and ca pricious. For

the following rea sons, we AF F IRM the orde r of the ma g istrate judg e. BACK GR OUNDNo. 08-4033

2 I. A. On Marc h 15, 2004, Mitz el beg an wor king f or Anthem, a subsidiary of Wellpoint , and joined Wel lpo int ’s F le xible B e ne fi t Pla n ( the “ Pla

n” ). An the m w a s th e Plan’ s a dmi nis tr a tor , w ith dis c re tio na

ry a uth or ity to i nte rp re t th e Plan a

nd fi na l a uth or ity in r e viewin g c la ims and a pp e a ls. The ter ms and conditions of Mitz el’s long -term disability benef its under the Plan ar e contained in thre e sepa

rate documents. The first document, ti tled “Anthem Flexibl e B enef its P lan and Summary Plan Desc ription” (the “Summ ary Plan Desc ription”) provides a g ener al, conde nsed g uide to Wellpoint employ ees’ health benef its a nd cover ag e. The fir st pag e of the Summary Plan De sc ri pti on

state s: “ Th is d oc ume nt, tog e the r wi th t he inc or po rate d d oc ume nts lis te d in Exhi bit C, constitute the written plan doc ument require d by Section 402 o f E R I S A an d the Summary Plan De sc ri pti on s r e qu ir e d b y

Se c tio n 10 2 of ERI SA. ” (A dmi nis tr a tiv e Re c or d (“ AR ” ) at 35 8. ) E xhibi t C of the Sum mary

Plan D e sc ri pti on

is a lis t of

the Plan’ s e ig ht c omp on e nt b e ne fi t pr og ra ms, including the L ong Term Disa bility Be nefit P rog ram (the “L TD Benef it Prog ram” ). A one- sentenc e pref ace to this l ist of prog rams states: “Component B enef it Progra ms are a vailable on the H R i n t r an e ts i t e u n l e s s o t h e r

w i s e n o t e d

. ” ( A R

a t3 8 7

. ) T h e L T D B e n e f i tP r o g r a m i s a

s e p ar a t e t h i rt yfi ve pa g e do c ume nt w hic h d e sc ri be s th e c on dit ion s f or lon g -t e rm

dis a bil ity be ne fi ts a s f

oll ow s: We w ill c ov e r your d isa

bil ity if it i s c a us e d b y , c on tr ib ut ed to by or re su lts fr om a pre- exis ting c ondition and y our disability beg ins after

y ou have be en insured f

or 12 c on se c uti ve mon ths a ft e r t he e ff e c tiv e date of c ov e ra g e . I f y ou do no t mee t this t ime period re quirement, y our disability is ex cluded f

rom cove rag e under

this plan. Pre-e xisting condition is a s ickne ss or injury: for which you rece ived treatme nt; ORNo. 08-4033

3 whe re sy mp tom s we re pr ese nt to th e de gr e e tha t an or

din ar ily pr ud e nt p e rso n wo uld se e k tre atm e nt; withi n the three m onths prior t o your effec tive date of cov erage. Tre atm e nt i nc lud

es: consulting wit h a doctor re c e ivin g car e or s e rv ic es fr om a d oc tor or fro m o the r m e dic al p ro

fe ssi on als a doctor recom mends y ou see taking prescribed m edicines being prescribe d medicine s y ou sh ou ld h av e be e n ta k ing pr esc rib e d m e dic ine

s b ut c ho se no t to re c e iv ing dia gn os tic me as ur es. (AR at 404-05) (for

matting in orig inal, with bullets omi tted). The L TD Benef it Progra m defines “ef fec tive date of

cover ag e” a s ninety

day s after the employ ee ha s beg un active e mploy ment, or June 13, 2004 in Mitz el’s ca se. (AR at 392.) A third rele vant document, e ntitled “ L o n g - T e r

m D is a b il it y : 2 0 0 5 B e n e fit Booklet” (the “ L TD Be nefit B ooklet”) a

nd consisting of

eleve n pag es, was also available for Pl an participants. The L TD Be nefit B ooklet includes a pr efa ce that states “Toge ther with the Anthem F lexi ble B enef its P lan and Summary Plan Descr iption, thi s document constitutes the written pla n document re quired by

Section 402 of ER I SA and the Summary Plan Desc ription require d by Section 102 of ERI SA.” (AR at 348.) Th e L TD B e ne fi t B oo kle t in c lud e s a se c tio n o n p re -e xistin g c on dit ion s w hic h s ta te s: Duri ngy our fi rs t 12 mon ths of c ov e ra g e , y ou wi ll no t be e lig ibl e to r e c e ive dis a bil ity benef its if y our disability

is caused by , contributed to by or re sults from a pre -existi ng condition. A pre- exis ting c ondi t i o n i s a s ickness or injury for whic h y ou rec eived me dic a l c are or se rv ic e s ( inc lud ingdo c tor vis its , p re sc ri pti on s and

dia g no sti c te sts ) during the three months prior to y our ef fec tive date of

cover ag e. (A R a t 35 0. ) T he la st p a g e of the L TD B e ne fi t B oo kle t in c lud e s the fo llo wi ng dis c la ime r: “ I n c a se of any conflict be tween this booklet and the Plan document, the provisions of the a ctual PlanNo. 08-4033

4 document will preva il. I t is y our re sponsibili ty to rea d, understand a

nd comply

with the policies descr ibed in this S ummary Plan Descr iption (SP D).” (AR at 357.)

B. I n J anuar y 2004, during an annua l phy sical with he r primary car e phy sician, Mitzel reported that she wa s experiencinghip pain. Her phy sician re fer

red he r to Dr. Raf

ael E. A rsuag a (“ Dr. Ar su a g a ” ) , w h o m e t w i t h M i t z e l o n M ar c h 2 , 2 0 0 4

. F o l l o w i n g t h i s v i s i t , D r . A r s u a g a w ro te to Mitz el’s primar

y car e phy sician that Mitzel “presents with acute onset of sy mptoms dating Oc tober of 2 0 0 3 w h e ni n i t i a l l y

s h e e xp e r i e n c e d

r i g h ts h o u l d e r

p a i nf o l l o w e d b y r i g h tl a t e r a l s h o u l d e r

p a in and nec k pain, low bac k pain, left hip pain a nd g ener alized malaise lasting sever al hours despite the use of NSAI Ds in the past.” (AR at 137.) D r. Arsua g a also stated that “positive antinuclea r antibody sp e c kle d p a tte rn , y oungfe ma le wi th a rt hr a lg ia s mi g ht s ug g e st the po ssi bil ity of S L E [Sy ste mic Lupus Ery

thematosis] but Iwoul d ex p ect to see much more c riteria be fore we c ould assure the dia g no sis

. Othe r pos sib ili tie s to con sid e r in the dif fe re nti a l dia g no se s ar e rh e umatoi d a rt hr iti s, a c ute thy roiditis.” (AR at 138.) Mit zel met with Dr. Arsua g a ag ain on Marc h 25, 2004 and Apr il 2, 2004, display ing a

rash on he r ar

ms and t h i gh s fo r the first time. After the Marc h 25, 2004 visit, Dr. Ar s u aga took a note that he w as now “ consider[ing ] m ore strong ly the possibilit y

of SL E,” a

nd

rec ommended to Mitz el af ter the A pril 2, 2004 visit t hat if her sy mptoms per sisted, she should see

ane ar - n o s e - an d

- t h r o a ts u r g e o nf o r a b i o p s y . ( A R a t 1 3 9

. ) D r . A r s u a g a c o n t i n u e d

t o s u s p e c tS LE and re commended a

biopsy afte r mee ting with Mitzel ag ain on May 6, 2004. Upon re ceivingDr. Ar suag a’s repor ts assessing Mitz el and se eing no improvement, Mitzel’s primary car e phy sician then re fer

red he r t o the C leveland Cli nic. On June 18, 2004–five day s afterNo. 08-4033

5 he r e ff e c tiv e date of

c ov e ra g e un de r t

he Pla n– the Cle ve land

Clin ic dia g no se d Mitze l f or the fi rs t ti me with Wege ner’ s g ranulomatosis (“WG”) , a life- threatening condition affe ctingmultipl e org ans. On J une 3, 2 0 0 5 , M it ze l w a s h o s p it a li ze d a s h e r WG d e te r io r a te d , an d

a c c o r d in g ly

to ok sh or t- te rm dis a bil ity le a ve fr om w or

k. On No ve mbe r 1, 20 05 , wi th he r sh or t- te rm dis a

bil ity be ne fi ts exhausted, Mitz el submitted a claim for long- term disability

benef its. By letter dated Ma

y 18, 2006, Anthem denied Mitz el’s claim. I n the letter, Anthem cited the de finition of “pre -existi ng condition” in t he L TD B e ne fi t B oo kle t, a nd no te d M itze l’ s th

re e vis its wi th D r. Ar su a g a duri ngthe thr e e -m on th look-bac k period of Ma

rch 13 to June 13, 2004. Although Dr . Arsua g a had ne ver c onsidered the possibili ty

that Mitz el h ad W G, Anthem neverthele ss advised Mitzel that “[ a]s y ou wer e having sy mptoms of y our condition and c onsulted with Dr. Arsua g a duringthe pre -existi ng time frame , y our condition qualifies as pre -existi ng and is excluded from c overa g e under the plan.” ( AR at 114.) On J une 8, 2006, Mitzel appeale d the Plan’s denial of long- term disabilit y . I n revie wing Mit zel ’s a

pp e a l, An the m re ta ine d an “ ind e pe nd e nt p hy sic ian s pe c ia lis t,” Ron a ld J. B loo mf ie ld, to evaluate Mitz el’s medica l history and cla im. (AR at 83.) Dr. B loomfield conclude d: Ms. Mit zel be c a me ill in Oc tob e r 200 3 with [WG]. She ha d mu lti ple me dic a l vi sit s prior to, during , and af

ter he r pre -existi ng time period. She was being examined by Dr. Ar suag a in Marc h and May 2004 for sy mptoms which wer e eventua lly diag nosed as [W G]. S he bec ame sy mptomatic from [W G] in Octo ber 2003 a nd was not diag nosed nor tre ated until J une 2004. The failure to make the diag nosis until a fe w day s afte r her pre- exis ting time pe riod ended is note d. Howeve r, s h e w as being examined by

Dr. Ar suag a for sy

mptoms which were caused by [W G].

. . . The fa ct that the d i agn osis was not confirme d until after she was hospitalized in J une 2004 does not cha

ng e the f act she was in the mi dst of an evaluation prior to her becoming so ill t hat she re quired a

leng thy hospitaliz ation. (AR at 93.) Ba sed on Dr. Bloomfield’ s assessment, the Plan upheld the denial of Mitz el’s long -term disability benef its.No. 08-4033

6 Mitz el made a

final appe al t o Anthem, s ubmitti ng letters from Dr. Arsuag a and the shoulder specia list who first evaluated her shoulder pain in October

2003. Dr. Ar suag a stated in his letter that wh en h e ev al uated Mitzel in March a nd May 2004, Mitz el did not meet the cr iteria for WG. The should er s p ec ialist stated, “Her problem at that time wa s for a n acute shoulder impinge ment tendonitis, which impro v ed by her la st visit with me on 12/4/03. Her proble m of shoulder impingeme nt tendonitis i s not a pre- exis ting condition to her cur rent diag nosis of [W G].” (AR at 50.) Anthem hire d another independe nt phy sician to assess Mitzel’s claim based o n h er medical

rec ords. The inde pendent phy sician confi rm ed Dr. B loomfield’s opinion, and by letter dated F e br ua ry 1, 20 07 , th e P lan Adm inistr a tor de nie d M itze l’ s f

ina l a pp e a l f or the same re a so ns it previously

stated. C. On J uly 3, 2007, Mitz el filed this ERI SA enforc ement action ag ainst Anthem and Wellpoint in district court, later a

mending her c omplain t t o ad d W el l point Flexibl e B enef it Pl an as a

third De fe nd ant. On

Oc tob e r 2 3, 20 07 , the pa

rt ie s c on se nte d to the jur isd ic tio n o f a ma g ist rate jud g e wi th respe ct to all issues, including d i s p o s i t ive ruling s. On Fe bruar y 15, 2008, Def

endants moved the court to uphold the denia l of bene fits, and Mitz el cr oss-moved for summary judgme nt in her favor. On J uly 14, 2008, the mag istrate judge g rante d Mitz el’s motion for summary judgme nt and

overr uled the administ ra t o r’ s d enial of Mitzel’s long- term disability benef its, because he found De fe nd ants ’ i nte rp re ta tio n o f “ pr e -e xistin g c on di ti on ” in t he Pla n to be arb itr ary

and c a pr ic iou s. Noting that the P lan’s definitions of “pre- exis ting c ondition” in the L TD B enef it Progra m and the L TD B enef

it Bookle t wer e differe nt, the m ag istrate judge stated that “[t] he court rests t he dec isionNo. 08-4033

7 on the d e f

in it io nin th e [L T D B e n e f

it B o o k le t] , w h ic h h a d

b e e nq u o te d in th e in it ia l d e n ia l l e tte r. Plan summaries g ener ally trump the lang uag e of the plans themselves.” (Recor d on Appea l at 340.) The c ourt then found that the definition of “pre -existi ng condition” in the L TD B enef it Booklet wa s ambig uous with respec t to whether it applied to a condition for which sy mptoms were r ecog nized during t h e l o o k -b ac k p eriod, but for which ther e had not be en an a ccur ate diag nosis or even a suspicion of the ac tual condit i o n . T h e cour t then applied the r

ule of contra proferentem –that ambig uities must be construed ag ainst the draf ter of the ambig uous lang uag e–to find t hat t he denia l of bene fits based on this lang uag e wa s arbitra ry and ca pricious. Def

endants timely

appea led. II. Th is C ourt

re vie ws de novo a district c ourt’s dec ision to gra nt summary

judgme nt upholding

or re versinga denia l of hea lth benefits pursuant to ERI SA. Ki ll ia n v . H e a lt h s o u rce Prov ident Adm’rs Inc

. , 152 F.3d 514, 520 ( 6th Cir. 1998). When an ERI SA plan g rants the plan a dminist rator disc retionar y authority to determine b e n e f i te l i g i b i l i t y , t h e d i s t r i c tc o u rtm u s tr e v i e w t h e p l ana d m i n i s t r a t o r ’ s d e c i s i o nu n d e r t h e ar b i t r a ryor-c apric ious standa

rd. Firestone Tire & Rubber Co. v. Bruc h , 4 89 U. S. 1 01 , 1 15 (1 98 9) ; Mc Do na ld v. W estern-Southe rn Li

f e Ins. Co. , 347 F.3d 161, 168 ( 6th Cir. 2003). I n this case, the Plan state s that A nth e m ha s “ the fu ll p ow e r t o ma ke fa c tua l de te rm inatio ns and to int e rp re t and a pp ly the te rm s of the Plan as they relate to the benef its provide d throug h this self-funde d Plan.” (AR at 379.) The parties do not dispute that the Plan g rants discre tionary authority to the P lan’s adminis trator, and that the ar bitrary -or- capr icious standard should ther efor e apply

.No. 08-4033

8 “This [arbitrary

and ca pricious] standard is the least demanding form of judicial revie w of administrative ac tion. . . .W hen it is possibl e to offe r a r easone d explanation, based on the e vidence , for a particula r outcome, that outcome is not arbitrar y or ca pricious.” Kill ian , 152 F.3d at 5 2 0. Under this standard, this Court “will uphold the administ rator’ s decision ‘if it is the result of a deliberate, principled r eas o n i n g p ro cess a nd if it is supported by

substantial evidence .’” Glenn v. M e tr o p o li ta n Li fe I n s . Co. , 4 6 1 F. 3 d

6 6 0 , 6 6 6 (6 t h C i r. 2 0 0 6 ) ( qu o t i n g Bake r v. United Mine W orkers of Am. He alth & Ret. Funds , 929 F.2d 1140, 1144 ( 6th Cir. 1991)), aff’d , 128 S. Ct. 2343 (2 00 8) . Y e t w hil e arb itr ary and c a pr ic iou s re vie w is def

e re nti a l, it “is no me re fo rm a lity [,]” and mus t consider “t h e quality

and quantity

of the medic al evidenc e and the opinions on both si des of the issues.” Glenn , 4 61 F .3 d at 6 66 (q uo ta tio ns and

c itatio n o mit te d) . “ Whil e a be ne fi ts p lan ma

y ve st discretion in the plan a dminist rator, the federal c ourts do not sit i n revie w of the a dminist rator’ s decisions only

for the pur

pose of r ubber stamping those dec isions.” Moon v. Unum Provident Corp. , 405 F.3d 373, 379 ( 6th Cir. 2005). Moreove r, this Court may consider, a s “a f

actor . . . when de termining whether the administrator’s de cision to de ny benef its wa s arbitra

ry and capr icious,” the c onflict of intere st that

e xists wh e n th e ins ur e r b oth de c ide s w he the r t

he e mpl oye e is e lig ibl e fo r benefi ts and pa y s th os e benef its. Evans v. U

numProvident Corp. , 4 34 F .3 d 8 66 , 8 76 (6 th C ir . 2 00 6). I n c on sid e ri ngthi s fac tor, “[t] he re viewing court looks to see if the re is evide nce that the conflict in any way influence d the plan administrator’ s decision.” Id. ( c i t a t i o n s o m i t t e d )

. T h r o u g h i t s A n t h e m s u b s i d i a r y, W e l l p o i n t b o t h f

u n d s an d a d m i n i s t e r s t h e P l an , an d t h e r e f o r e a c t s u n d e r t h i s c o n f

l i c tof int e re st. Howeve r, Mitzel does not argu e b efor e this Court that the conflict influenc ed the de nial of herNo. 08-4033

We note that the Plan documents themselves a re f ar f rom clea r as to which one is the 1 summary document. The L TD B en ef i t Bo oklet contains a discla imer that it is the summary document with re spect to long -term disability benef its. Ho we v er , t h e Summary Plan Descr iption also states that it and the component pr og rams listed in Ex hibit C constitute bo th the Plan and the summary document. Compounding the confusio n is the fa ct that both the Summary Plan Descr iption and the L TD B e ne fi t B oo kle t r e fe r t o th e mse lve s a s th e “ Sum mary Plan D e sc ri pti on ” in s ome pla c e s. W e f a i l t o u n d e r s t an d h o w t h e s e o v e r l a p p i n g d o c u m e n t s , e a c h p u r p o rt i n g t o c o n s t i tu t e a

“ s u m m a r y” 9 disability benef its, and has provided no e vidence of bias. According ly , we plac e little emphasis on thi s fa c tor , thou g h we no te that whe re an insure r fund s a nd a dmi nis te rs a

pla n, “ the re is a

n a c tua l,

rea dily appar ent conf

lict . . . not a mere potential for one .” Kill ian , 152 F.3d at 521.

“ [A]bs e nt a

pr oc e dura l c ha lle ng e to t

he pla n a dmi nis tr a tor ’s de c isi on , thi s Co ur t’ s r e vie w i s limit ed to the administrative r ecor d of the be nefit dete rmination.” Evans , 434 F.3d at 876. III . The mag i s t ra t e judge, in dete rmining w hether Anthem’s interpr etation of “ pre- exis ting

c on dit ion ” wa s arb itr ary

and c a pr ic iou s, c on sid e re d o nly

the de fi nit ion

in t he L TD B e ne fi t B oo kle t, beca use “[p]l an summaries ge nera lly trump the l ang uag e of the pl ans themselves.” (ROA at 340.) On appe al, Def

endan t s argue that the mag istrate judg e impermissibly ignor ed the Plan’s other do c ume nts in f

oc us inge xclu siv e ly

on the L TD B e ne fi t B oo kle t. ERI SA r e qu ir e s a

pla n p ro vid e r t o d istri bu te a

su mma ry pla n de sc ri pti on to a ll p art ic ipa nts and bene ficiar ies. 29 U.S.C. § 1021(a)( 1 ). T h e summary plan desc ription must “be written in a

mann e r c a lc ulate d to be un de rs too d by the a ve ra g e pla n part ic ipa

nt, and sh a ll be su ff

ic ie ntl y a c c ur a te and compr ehensive to rea sonably appri s e s u ch participa

nts and bene ficiar ies of their r ights a nd

o b l i g a t i o n s u n d e r

t h e p l a n . ” § 1 0 2 2 ( a )

. D e f

e n d an t s h a v e n o td i s p u t e d t h a tt h e r e l e v an t“ s u m m a r y” do c ume nt f

or the purp os e s o f § 10 21 (a )( 1) is the L TD B e ne fi t B oo kle t. 1No. 08-4033

of the Plan, could possibly fulfill the mandate in § 1021( a)( 1) to provide a clea r, conc ise summary for Plan par

ticipants. 10 “This Circuit has dec ided that statements in a summary plan ar e binding an d if such statements conf

lict with those in the pla

n itself, the summary shall g overn.” Ed war ds v . S tat e Fa rm Mut. Auto. Ins. Co. , 85 1 F .2 d 1 34 , 1 36 (6 th C ir . 1 98 8) ; Haus v. Bechtel Jacobs Co. , 491 F.3d 557, 564 ( 6 th Ci r . 2 0 0 7 )

. T h is r u le is p r e mi s e d o n th e r a ti o n a le th a t “ [i ]t is g r o s s ly u n f a ir to hold an

e mpl oy e e a c c ounta

ble fo r a c ts wh ic h disq

ua lif y him fr om be ne fi ts if he ha d n o k no wl e dg e of

the se acts or if these c onditions we re stated in a misleadingor incompre hensible manne r in the plan booklets.” Ed

war d s, 851 F.2d at 136 (quotations and citation omitted). Thus, “[i] t is of no eff ect to publish and distribut e a pla n summary

booklet desig ned to simplify and ex plain a voluminous and complex document and then proc laim that any i nconsistencies w ill be gove rned by the plan.” Id. (quotations and citation omitted). Howeve r, “[a]n omiss ion from the summary plan descri p t i o n d oes not, by neg ative imp lic a tio n, a lte r t

he te rm s o f t

he pla n it se lf . T he re a so n is ob vio us : by de fi nit ion , a su mma

ry wi ll not inc lude ever

y detail of the thing it summ arizes.” Sprague v. Gen. M otors Corp. , 133 F.3d 388, 4 0 1 (6 t h C i r. 1 9 9 8 ) ( en b an c) (c i t at i o n s o m i t t ed ). Fu rt h er , “u n d er t h e l aw o f t h i s ci rc u i t , l an gu age i na p l an s u m m ary

t h at i s m er el y

am b i gu o u s s h o u l d

n o tb e p er m i t t edt o t ru mp u n am b iguo u s l an gu age in the plan itself[.] ” Foltice v. G uardsman Prods., Inc. , 9 8 F .3 d 9 33 , 9 38 (6 th C ir . 1 99 6) ; se e als o L a ke v . Metropolitan Lif e Ins. Co. , 7 3 F

. 3 d 1 3 7 2 , 1 3 7 9 ( 6 t h C i r . 1 9 9 6 ) ( r e s o l v i n g a m b i g uit y in summary plan desc ription by

ref err ing to c larify

ing la ng uag e in plan docume nts)

. T h u s , wh i le a

c on fl ic t e xists wh e re the su mma ry pla n de sc ri pti on mis le a ds or fa ils to s ta te a dd iti on a l r e qu ir e me ntsNo. 08-4033

11 contained in the plan document, see Ed war d s, 851 F.2d at 136, there is no conf lict where the plan document mer ely

clar ifies the summary ’s g ener al lang uag e, see Foltice , 98 F.3d at 938. The L TD B enef

it Booklet provides notice that to the extent that any conflict e x ists between its ter ms and

the pr ima

ry Plan d oc ume nts , th e pr ima ry Plan d oc ume nts c on tr ol. Ho we ve r, a s th is Court stated in Edwards , E RI SA d oe s n ot a llo w p la n p ro vid e rs to s ho rt -c ut t hei r ob li gati on s to provide c lear , compre hensive summary plan descriptions by including a conclusory war ning in the summary that the more detailed plan document controls in c ase of conflict. Thus, reg ardle ss of the Plan’s disclaimers, to the ex tent that the provisi ons in the L TD Benef it Prog ram contradict the L TD B e ne fi t B oo kle t and

mis lea d a

Plan me mbe r, thi s Co ur

t mu st f a vo r t he te rm s in

the L TD B e ne fi t B oo kle t. The L TD B enef

it Bookl et states that “[a] pre-e x isting condition is a sickness or injury for wh ic h y ou

re c e ive d me dic a l c are or se rv ic e s ( inc lud ingdo c tor vis its , p re sc ri pti on s a nd dia g no sti c tests) duri n g th e thr e e mo n th s p r io r to y o u r e f f e c ti v e d a te o f c o v e r a g e . ” ( A R a t 3 5 0

. ) The L TD Be nefit Prog ram de fines “pr e-e x isting c ondition” as “a sickness or injury

for whic h y ou rec eived tr e a tme nt O R w he re sy

mpt oms we re pr e se nt to the de g re e that an or din ari ly pr ud e nt p e rs on

wo uld seek tre atment” dur ing the three -month look-back pe riod. (AR at 404.) The sec ond part of the L TD Be nefit Prog ram’s de finition, which focuse s on whether sy mptoms of the disabilit y

wer e present during t h e l o o k-bac k period, de parts fr om the definition in the L TD B enef it Booklet. The L TD B e n e f i tB o o k l e t r e q

u i r e s ane mp l o ye e t o h a v e r e c e i v e d “ m e d i c a l c ar e o r

s e r v i c e s ” f o r t h e d i s a b i l i t y, wher eas the L TD Be nefit Prog ram could enable an employ ee to ha ve a pre- exis ting condition even if the employ ee did not see k or re ceive any medical attention, but merely exhibi ted sy

mptoms of aNo. 08-4033

With ou t c omm e nti ngon thi s ana ly sis or on the inc on sis te nc ie s bet we e n the L TD B e ne fi t 2 Bookle t and the L TD B en e f it Prog ram, the dissent re fer s to the “ordinar ily prudent pe rson” languag e. Not only is this refer ence misplaced for the re asons stated, but our a naly sis would remain uncha ng ed since Mitzel did seek treatment for her sy mptoms i n any

case . 12 disease f or which tre atment beg ins after the effec tive date of cover ag e. W e believe this dist inction in t he de fi nit ion s is mis le a din g , b e c a us e no thi ng in t

he L TD B e ne fi t B oo kle t w ou ld i nd ic a te that a doctor’s ide ntification of sy mptoms of a subsequently diag nosed illness during the look-bac k period, by itself, could satisfy

the definition of a pr e-e x isting condition. Acc ording ly , we will not countena nce the part of the L TD B enef it Progra m’s definition that ref

ers to sy mptoms. Howeve r,

2 beca use the re mainder of

the def inition i n the L TD B enef it P ro gram appear s to be a c onsistent

e la bo ratio n of the de fi nit ion in the L TD B e ne fi t B oo kle t, thi s Court may c on su lt it to the e xten t it clar ifies any

ambig uities in the L TD B enef it Booklet. See Foltice , 98 F.3d at 938. IV. F o c u s in g o n th e d e f

in it io n o f “ p r e - e xis ti n g c o n d it io n ” in th e L T D B e n e f it B o o k le t, the mag istrate judg e found a

mbiguity with respec t to whether Mitz el’s treatment for the sy mptoms of WG during the three -month look-back pe riod qualified he r WG as a “ pre- exis ting c ondition.” The mag istrate judg e then ruled for Mitz el by resolving the ambig uity ag ainst the Plan’s draf ter pursua nt to the doctrine of contra proferentem

. As an initial matter , we are troubled by the mag istrate judg e’s r eliance on the rule of c on tra proferentem in t

his c a se . T o b e sure , this Court ha s invo ke d th e ru le in p re vio us ERI SA d isp ute s, holding that “ to the extent that the Pl an’s languag e is su s ce p t i b le of more than one inter pretation, we will . . . construe any

ambig uities ag ainst . . . the draf ting pa rties.” U n i v . H o s p s. of ClevelandNo. 08-4033

13 v. Eme rson Elec. Co. , 2 02 F .3 d 839 , 8 46 -4 7 ( 6th Cir . 2 00 0) ; se e als o Perez v . Aetna Life Ins. Co. , 15 0 F. 3d 55 0, 55 7 n.7 (6 th C ir . 1 99 8) (e n b anc ); Marquette Gen. Hosp. v. Goodman Forest Indus ., 315 F.3d 629, 632 n.1 ( 6th Cir. 2002). Ho we ve r, in c a se s su c h a s th is o ne , in whi ch th e ad

min ist rator ’s de nia l of

be ne fi ts i s revie wed unde r the a

rbitrar y and ca pricious standar d beca

use of the disc retion conf

err ed by the Plan,

we b el i ev e that invoking the r ule of contra proferentem undermines the a rbitrar y and ca pricious sta nd ard of re vie w. Un de r t

he arb itr ary

and c a pr ic iou s st and ard , c ourt s mu st favor a plan administrator’s interpre tation ove r an equally rea sonable contra ry interpre tation. See, e .g., Morgan v. SKF USA, Inc

. , 385 F.3d 989, 992 ( 6th Cir. 2004) (“We must acc ept a plan a dminist rator’ s rational interpre tation of a plan eve n in t h e f ace of an e qually rational i nterpretation offered by the pa rti c ipa nts .”) ( emphasis added). Moreove r, although t his Court appear s to have a pplied the c on tra proferentem doctrine w hen re viewing under the arbitra ry and ca pricious standar d, se e Un ive rsi ty Ho sp ita ls , 202 F.3d at 850, sever al circ uits have held that the rule of contra proferentem does not apply wher e a pla

n bestows interpre tat ive authority on its administ rator. See W inters v. Costco W holesale Corp. , 49 F.3d 550, 554 ( 9th Cir. 1995) (“ We hold that the rule of contra proferentem is not applicable to se lf-funde d ERI SA plan s t h at bestow explicit di scre tionary authority upon an

a dmi nistra tor

to d e te rm ine e lig ibi lity

fo r b e ne fi ts o r t o c on str

ue the te rm s o f t

he pla n. ” ); Pagan v. NY NEX Pension Plan , 52 F.3d 438, 443 ( 2d Cir. 1995) (“[A]pplicati o n o f t he rule of c on tra proferentem is limited to those occa sions in which this Court re views an ERI SA plan de novo .” ); Lee v. Blue Cross/Blue Shield of Ala. , 10 F.3d 1547, 1551 ( 11th Cir. 1994) (noting, a fter ci t ing c ases from seve n other c ircuits that invoked contra proferentem rule in ERI SA context, t hat “a ll of theNo. 08-4033

14 cited case s except [one] involve a de novo revie w of the challeng ed insuranc e plan” ). L imiti ng the application of the contra proferentem rule to case s in which an a dminist rator’ s decision is review ed de novo strikes us as the only sensible appr oach to r esolving ambig uities in plan documents. Reg ardle ss, the lang uag e of the L TD B enef it Booklet is unambig uous in supporting Mitzel’s argument that she did not have a pre- exis ting condition. “In interpre ting a plan, the administrator must adhere to the plain meaningof its lang uag e as it would be construed by an ordina ry person.” Morgan , 385 F.3d at 992. “I n applying the ‘plain m ea n i n g’ analy sis, we must give eff ect to the unambig uous terms of an E RI SA pl an.” W illiams v. Int’l Paper Co. , 227 F.3d 706, 711 ( 6th Cir. 2000) (quotations and c itations omi tted). T h e L T D B e n e f

i tB o o k l e ts t a t e s t h a ta

p r e - e x i s t i n g c o n d i t i o ni s “ a s i c kn e s s o r

i n j u r y for which [Mitze l] re c e ive d me dic a l c are or se rv ic e s. ” (A R a t 35 0. ) (e mph a sis a dd e d)

. Al tho ug h b oth docum en t s g o on to list some of the a ctions that would qualify as “tre atment” or

“medica l car e or service s,” bot h constructions re quire the me dical attention to be for the pre- exis ting condition. The Third Circuit, interpre ting a simil ar “pre -existi ng condition” definition in a health car e plan in the context of a contra ctual dispute, provided a n analy sis of the word “ for” that this Cou rt finds persua sive: The wor d “for ” connote s inten t

. W eb ster’s Dic tionary states that “f

or” is “use d as a func tion word to indicate purpose .” Webster’ s Ninth N ew Collegiate Dictionar y 481 (1986). B lack’ s L aw Dic tionary simil arly states that the wor d “connote s the end with refe renc e to wh i ch any thing is, ac ts, serves, or

is done. I n consideration of which, in view of

which, or w ith refe renc e to which, a ny thing is done or takes plac e.” Bla ck’s L aw Dic tionary

579-80 (5th ed. 1979)

. . . . I n short, it is hard to see how a doctor c an provide treatment “for” a condition wit hout knowing w hat that condition is o r t hat it e ve n e xists

.No. 08-4033

The d i s s en t at t em p t s to cite a dictionar y as we ll for a de finition of “for.” I ts definition, 3 m e an i n g “ b e c a

u s e o f , ” i s d e f i n i t i o n8 ( a ) i nW e b s t e r ’ s T h i r d N e w In t e r

n a t i o n a l D i c t i o n a r

y, Unabr i dg ed (2002) . Counting subsec tions, W ebster’ s lists twenty differ ent def

initions befor e the on e re lie d o n b y

the dis se nt. F ur

the rm or e , th e e xamp le in t he dic tio na

ry fo r t he de fi nit ion

“ be c a us e of” is “shoute d for joy ,” which is not at all how the ter m is used in the Plan. The same dictionar y ’s de fi nit ion 3( c )( 2) is “ on

the po int of : ha vin g the int e nti on

of .” Th e dic tio na

ry ’s e xamp le is “ wa s ju st for g oing to bed.” The langua g e in the P lan m ore closely para llels the us ag e in this definition. The dissent’s use of “ beca

use of” as the a

ppropriate definition of “for ” is not at all the “pla in meaning of [the Plan’s] lang uag e as it would be construed by an ordinary person.” Morgan v. SKF USA, I nc. , 385 F.3d 989, 992 ( 6th Cir. 2004). The dissent attempts to extend LoCoco far bey ond what it actua lly

holds. J udg e McK eague 4 c ite s LoCoco following his assertion that “a patient ca

n have dia g nostic tests for a sickne ss even though ne ither the patient nor the doctor suspected or corr ectly diag nosed the sickne ss at the time.” Dissent at 4. LoCoco dealt with a patient who was suspected of having lung c ance r but who had not been of ficially diag nosed prior to cover ag e. I t cites numerous c ases whe re c ourts have e mphasized that testing f

or a suspe cted but undia g nosed illness satisfy simil ar “for which” lang uag e. 530 F.3d at 447-48. Nothing in the case states that treatme n t fo r s y m p t o ms of an unknown illness ar e sufficie nt to satisfy “for which” lang uag e. I f Mitzel’s doctors had strong ly suspected WG but had not rec eived the r esults of diag nostic testing be fore cover ag e beg an, this would be a differ ent ca se. 15 Lawson ex rel. Lawson v. Fortis Ins. Co. , 3 0 1 F

. 3 d 1 5 9 , 1 6 5 ( 3 d

Ci r . 2 0 02); s ee a lso McLeod v. Hartford Li

fe and Acc ident Ins. Co. , 372 F.3d 618, 626 ( 3d Cir. 2004) (“F inding the Lawson ana ly sis persua sive, we c onstrue the term ‘for’ to contain the Lawson e le me nt o f i nte nti on a lity [in the ERI SA context] .”). This Court has also previously opined in dic ta t h at “the wor d ‘for ’ ca n be re ad as 3 connoting intent or purpose rega rding the condition, such that treatment cannot be g iven ‘for ’ a specific condition unle ss the nature of the c ondition is known.” LoCoco v. Medic al Sav. Ins. Co. , 530 F.3d 442, 447 ( 6th Cir. 2008). We further note d in LoCoco that “ in [ERI SA] c a se s that de a lt with clauses r efe rringto conditions ‘for which’ treatment was provided . . . courts have conclude d that the ultimate condition need only have be en suspected wit h a reasonable degre e of likelihood in order to be consider ed ‘pr e-e x isting.’” Id. at 447-48 (e mphasis added)

. 4No. 08-4033

16 The dissent quibbles with our use of the Third Circuit prece d en t , arguing w ithout support from any case that, “the ty

pes of medic al car e or treatment spe cified by the Plan [do not ] require that the doctor or the patient cor rec tly diag nose or e ven suspec t during the pre -existi ng period the a ctual sickness that is ultimately

diag nosed.” D issent at 3. The dissent continues to boldly asser t how clea r the Plan lang uag e is but supports its argument only with a dictionary definition of “sickne ss” and the afor ementioned mis leadingdictionary definition of “f

or.” It relies on no additional languag e of the Plan and no case law. This lack of support is not surprising beca use t he st atement that a pre exis ting

c on ditio n is “a

sic kn e ss o r i nju

ry fo r w hic h y ou

re c e ive d tr e a tme nt” in n o w ay un a mbi g uo us ly encompa sses treatments for sy mptoms of an undiag nosed i llness. Given the dissent’s lac k of cited authority , it a

ppear s no court in this country has rea d a similar clause the way that J udg e McK eague finds is so clear . The much more logic al rea ding is that the Plan re quires some knowle dg e of w hat the sic kn e ss i s in

or de r t o p ro vid e tr e a tme nt for the sickness. I n denying Mitzel’s long -term disability claim, the only

ref ere nce Anthem made to Mitzel

rec e iv in g tr e a tm e n t w a s th a t M it ze l “ c o n s u lt e d w it h D r . A r s u a g a ” w h il e d is p la y in g s o me of the sy mptoms of W G. (AR at 114.) Howeve r, Dr. Arsuag a stated that when he evaluated Mitz el during the look-bac k peri od, Mitz el did not meet the cr iteria for WG. Further

more, nothing in the administrative re cord indicates t h at Dr

. Arsuaga had eve n an inkling that Mitz el might have WG, let alone “ suspected [WG] with a rea sonable de g ree of likelihood,” see LoCoco , 530 F.3d at 447-48. Be cause none of Mitzel’s phy sicians eve n considere d the possibilit y that she had WG bef

ore her

e f f e c ti v e d a te o f c o v e r a g e , n o n e o f th e m tr eate d her for WG, notwiths tanding the fa ct that she display ed some of the sy

mptoms of that disease. I t was unre asonable for Anthe m to deny Mitz el’sNo. 08-4033

J udg e McK eague’s e mphasis on the definition of “sickne ss” is somewhat confu s i n g. 5 Whe the r “ sic kn e ss” sta

nd inga lon e re qu ir e s a dia g no sis is ir re le va nt wh e re the Plan unambi g uo us ly require s that the treatment be for the sickness. In this case, the sic kness is WG, and Mitz el re ceive d no tr e a tme nt for WG dur ing the look-bac k period when the treating phy sician had no idea that she suffe red f rom that “sickne ss.” 17 claim simply

beca use she pr esente d sy

mptoms associated wit h a l ater-diag nosed disease and consulted with a doc tor during the l ook-bac k period in connec tion with thos e sy mptoms, where the doctor did not suspect, diag nose or treat the specific disability for whic h she eve ntually applied for be ne fi ts. 5 Our re ading of “pr e-e x isting condition” in the L TD Be nefit Bookle t is supported by the par t of the definition in L TD B enef it Progra m that we ar e fr ee to c onsult. To reiterate, we f ind the entire explanation of “pre -existi ng condition” i n the L TD B enef it Progra m consistent with the definition in the L TD B enef

it Booklet, except for

t h e p hrase “a sic kness or injury wher e sy mptoms were prese nt to the deg ree that an ordinarily prudent person would seek tre atment.” The non-conf licting part of the L TD B enef

it Progra m’s definiti o n states that a pr e-e x isting condition is “a sickne ss or i n j u r y for which [Mitze l] re c e ive d tr e a tme nt. ” (A R a t 40 4) (e mph a sis a dd e d)

. Th e L TD Ben e fi t Prog ram lists a number of examples of “tre atment,” but notably , does not includes medica l attention for sy mptoms of a disease that is later diag nosed. Be cause neit h er t h e definition of “pre- exis ting c ondition” in the L TD B enef it Booklet nor the elabor ation of the de finition of “t re atm ent” in the L TD B enef it Progra m includes a doc tor’s consideration of sy

mptoms which he was una ble to connec t to a subsequently diag nosed disease , Anthem’s denia l of bene fits based on this lang uag e was arbitra ry and capr icious. Acc ording ly , theNo. 08-4033

18 district court wa s corr ect to re verse Anthem’s dec ision, even if re sort to the rule of con tra proferentem may

not have be en appr opriate.

CO NC LU SION For the re asons set for

th above, we AF F IRM the judg ment of the district cour t.No. 08-4033

19 McK EAGU E, Circuit Judge, dis senting. Although w e re view the plan a dminist rator’ s decision under

the ar bitrary and capr icious standard, I also would “adhe re to the pla in meaning of [the Plan’s] lang uag e as it would be construed by an ordina ry person,” Morgan v. SFK USA, I nc. , 385 F.3d 989, 992 (6th Cir. 2004), and g ive “e ffe ct to the unambig uous terms of an ERI SA plan.” W illiams

v . I n t’ l P a p e r Co. , 2 2 7 F. 3d 706, 711 (6th Cir. 2000) (c itations omi tted). Howe ver, unlike the majority , Ibelieve that the lang uag e in the L TD B ene fi t Bo oklet and the L TD B enef it Progra m unambig uously

supports p la

n a d mi nistrator Anthem’s de cision to deny plaintiff-a

ppellee Ruth Mitzel long- term disability

benef its. Cons equently , Iwould reve rse the district c ourt. During the f

ir s t twelve months of cove rag e, the long -term disability plan (“ the Plan”) pr ovides a look-ba ck period for the thre e months prec eding the Plan’s ef fec tive date of

cover ag e. I f a pr eexis ting c ondition (a condition arising during this look-back per iod) i s found, then pa rticipants ar e not eligible f

or disability

benef its. Thus, the definition of pre- exis ting c ondition is centr al to this case. The L TD B enef

it Booklet def

ines a pre -existi ng condition as , “a sic kness or injury for whic h y ou

rec eived medic al ca

re or service s (including doctor visits, prescr iptions and diag nostic tests) during th e t h re e months prior to y our ef fec tive date of

cover ag e.” ( AR 350.) The L TD B enef it Progra m f u rth e r s tate s th a t a

“ [p ]r e - e xis ti n g c o n d it io nis a s ic kn e s s o r

in ju r y : f o r w h ic h y o ur e c eived tr e a tme nt; OR wh e re sy

mpt oms we re pr e se nt to the de g re e that an o rd ina ri ly pr ud e nt p e rs on

wo uld seek treatment.” (AR 404) (emphasis remove d and formatting chang ed from the original). The L TD Be nefit Prog ram define s “trea tment” to “includ[e]”: “[1] consulting w ith a doctor [2] rec eiving car e

or ser vices from a doctor or from other medical profe ssionals a doctor r ecommends you see . . . [3]No. 08-4033

20 rec eiving diag nostic measure s.” (AR 404-405) (empha sis removed a nd formatting chang ed fr om the orig inal). The diff iculty in this case ar ises beca use Mitzel developed sy mptoms of W eg ener ’s g ranulomatosis (“WG”) in 2003. The ef fective date of

her long -term disability

cover ag e wa s J une 13, 2004, so the look-bac k period ra n from Mar ch 13, 2004 to J une 13, 2004. Mitz el was hospitalized

on June 3, 20 04 , b ut n ot d ia g no se d w ithWG unti l June 18 , 2 00 4, fi ve da y s a ft er he r e ff

e c tiv e date of cove rag e. In decidingwhether her c laim w as for a pre- exis ting c ondition, Anthem relied on the expert analy sis of Dr. Ronal d J

. Bl o o m fi eld. Dr. Bloomfield found that Mitzel had WG before Oc tob e r 2 00 3, sh ow e d the sy mpt oms of WG by Oc tob e r 20 03 , a nd ha d me dic a l vi sit s to inv e sti g a te the sy mpt oms of

WG d ur ingthe loo k- ba c k pe ri od

. F ur the rm or e , Mit zel re c e ive d re pe a te d d ia g no sti c tests and diag nostic measure s during the pre -existi ng period for the condition later de termined to be WG and its sy

mptoms. (AR 36). I n analy zing the applica

ble lang uag e in the L TD Be nefit B ooklet, the majority focuse s on the “for which” la

ng uag e, building of

f ea rlier de cisions in the Third Circuit. See Lawson ex rel. Laws on v. Fortis Ins. Co. , 301 F .3 d 159 , 165 (3 d Ci r. 20 02 ); McLeod v. Hartford Li fe & Acc ident Ins. Co. , 372 F.3d 618, 625-26 (3d Cir. 2004) (relying on Lawson ). The Lawson and McLeod courts adopte d a def inition of “for” that “connote s intent” or is “‘use d as a f unction wo rd t o i n d i cate purpose.’ ” Lawson , 3 01 F .3 d at 16 5 ( c iti ngWeb ste r’ s N int h N e w C oll e g ia te Dic tio na ry 48 1 ( 19 86 )) . T he se Th ir d Ci rc uit

op ini on s th e n in te rp re te d th is l angua g e to r e qu ir e that th e me dic a l c are pr ov ide d mu st have be en in t en d ed t o t reat the claimant’s dia g nosed or suspec ted sickness. Put another w ay , the Third Circuit interpre ted the “for which” l ang uag e to require that the doctor or t he patient diag nosedNo. 08-4033

21 or suspec ted during the pre- exis ting period that the patient had the specific sickness that the patient was ultimately

diag nosed wi t h and that tre atment was intende d for that spe cific dia g nosed or

su sp e c te d s ic kn e ss. Howeve r, neither

the def inition of sickne s s n o r

th e ty p es of medic al ca

re or treatment specified by the Plan require that the doctor or the patient cor

rec tly diagnose or e ven suspec t during the pre

exis ting pe riod the ac tual sickness t hat i s ultimately diag nosed. First, as stated i n the P lan’s languag e, the medica l car e is not pr ovided “for ” a diag nosed or suspected sickness, it is simply provided for a

“ sic kn e ss, ” wi tho ut a

ny ini tia l mo dif

ie rs . T he de fi nit ion

of sic kn e ss i s b ro a d: 1 a : th e c on dit ion of bei ng il l : ill he a lth: il lne ss b : a disorder ed, we akene d, or unsound condition 2 : a f o r m o f d i s e a s e : m a l a dy W ebst er ' s T h i r d N ew International Dictionary, Unabridged (2002) available at htt p:/ /un a br idg e d. me rr iam- we bs te r. c om ( 1 O c t. 2 00 9)

. A sic k pe rs on ha s the c on dit ion of be ingill , a for m of disease , ill health, or a we akene d, disordere d, or un s o u n d co n dition even if neither the do c tor no r t he patie nt d ia g no se d o r s us pe c te d th e act ual si c kn e ss t hat th e patie nt w a s u lti ma te ly diag nosed with. I n this case, ther e is no dispute that Mitz el was sick with WG duringthe pre -existi ng period, e ven thoug h neither she nor her doctors diag nosed or suspected that she had WG during the pre- exis ting pe riod. Fur thermore , the re maining la ng uag e in the Plan conf

irms that the Plan doe s not require that the sickness be diag nosed or suspec ted by the doct o r or the patient duringthe pre -existi ng period. The L TD B enef

it Booklet def

ines pre- exis ting c ondition to i nclude “ a sickne ss . . . for which you

rec eived medic al ca

re or service s (doctor visit s, presc riptions and diagnostic tests).” A patient ca nNo. 08-4033

22 have doc tors visits for a sickness, even though neither the patient nor the doc tor corr ectly diag nosed

or su sp e c te d th e sic kn e ss a

t th e tim e . M or e ov e r, a

patie nt c an h ave diag no sti c te sts fo r a sic kn e ss, even thoug h neither the patient nor t h e d o ct o r sus pecte d or cor rec tly diag nosed the sickne ss at the time. See LoCoco v . Medic al Savings Ins. Co. , 530 F .3 d 4 42 , 4 47 (6 th C ir . 2 00 6) (“ L og ic a lly , a pa rt y do e s no t re c e ive a dia g no sti c c on c lus ion un til a ft e r a c tua lly un de rg oin g so me kin d of d iagno stic pr oc e ss. ” ). Simi larl y , th e L TD B e ne fi t Pr og ra m de fi ne s “ tr e a tme nt” (a te rm sy no ny mous w ith medical c are or services) to include consulti ng with a doctor, rec eiving car e or se rvice s from a doc tor

or fr om oth e r m e dic a l pr of

e ssi on a ls a

do c tor re c omm e nd s y ou

se e , o r r e c e ivi ngdia g no sti c me a sure s. None of these ty

pes of treatment require a correc t diag nosis of t he dis ease at t he ti me t he tre atment is provided; in fac t, they do not even require that the disease be suspec ted at the time the tre atment is p ro vid e d. I ns te a d, the y a ll e nv isi on

tr e a tme nt o f a

n und ia g no se d o r u

ns us pe c te d s ic kn e ss, pr e su ma bly a s p art of a pr oc e ss o f r e a c hin g a

c or re c t di a g no sis

. This lang uag e make s it clear that the Plan does n o t require that the doctor or the patient dia g no se or

su sp e c t du

ri ng the pr e -e xistin g pe ri od that th e patie nt h a s th e sp e c if ic un de rl y ingsic kn e ss that is ulti mately

diag nosed. Rather , the Plan require s that, during the pre -existi ng period, the patient had an unde rly ing sic kness and that he or she r ece ived one of the ty pes of medical c are or treatment specifie d in the Plan’s documents for that sickness. Consequently , the “for which” lang uag e in t he Plan does not require that the doctor intend to provide treatment for a specific diagnose d or suspec ted sickness. Instead, it requir es that the patient receive me dical ca re or treatment “bec uase of

” the

un de rl y ingsic kn e ss, re g ard le ss of wh e the r that sic kn e ss is d ia g no se d o r s us pe c te d. I nd e e d, thi s is in k e e p in g w it

h th e d e f in it ion of for. W

ebster's Thi rd New International Dictionary, UnabridgedNo. 08-4033

23 (2002), available at

http:// unabridg ed.mer

riam-we bster.com (13 Oct. 2009) (noting that “for ” mea ns “8 a : be cause of”)

. I n th is c a se , D r. B loo mf

ie ld’ s r e po rt

state d that Mitzel “ be c a me ill in O c tob e r 2 00 3 w ith Wegne r’s” and that she ha d “multiple” medica l visit s and examinations during the pre- exis ting pe riod for “ sy mptoms which were eventua lly diag nosed as Wegne r’s.” (AR 93). Conseque ntly , Mitz el had a sickne ss (WG) duri n g t h e p re -existi ng period a nd she re ceive d medical c are and tre atment as define d under the plan (doc tor visits, diag nostic tests, and diagnostic mea sures) be cause of or f or that sic kn e ss. Th e fa c t th a t Mi tze l and he r d oc tor s d id n ot s uspe c t or c or re c tly dia g no se the sp e c if

ic

s i ck n es s t h at s h e h ad(W G) d u ri n g t h e p re -e x i s t i n g p er i o d i s n o tre l ev an tb ec au s e t h e P l an ’s l an gu age simply does not requir e the doc tors (or Mitzel) to diag nose or suspect t h e ac t ual sickness that they

wer e p r o v id in g tr e a tm e n t f o r d u r in g th e p r e - e xis ti n g p e r io d

. T o r e d e f in e th e Pl an to require knowledg e or suspicion of the specific sickness that the patient is se eking treatment f or is to redef

ine the plain words of

the Plan – to add additional re quirements to the Plan. Since I am unwilling to do thi s, Iwo uld

re ve rs e the dis tr ic t c ourt

and up ho ld A nth e m’ s d e nia l of be ne fi ts.No. 08-4033

24 Ho ls c hu h, D is t r ic t J ud g e , c o nc ur r in g in t he a ffi r m a nc e o f t he j ud g m e nt . Ifully ag ree with J udg e Clay

that the Mag istrate Judge’ s decision should be af firmed a nd that Mitz el’s long -term disability benef its should be reinstated. Howe ver, I rea ch t h at conc lusion for somewhat diff ere nt

re a so ns . I. AnyEr r or of the M ag ist r at e Judg e in Re lyi ng Sole ly on the De finit ion of a “P r e -E xis ti ng Co ndit ion ” C ont ain e d in t he LTD Be ne fit Boo kle t wa s Ha r m le ss. The fir st issue on ap peal is whe ther the Ma g istrate Judge e rre d in relying sole ly on the de fi nit ion of a “ pr e -e xistin g c on dit ion ” c on ta ine d in the L TD B e ne fi t Bo ok let wi tho ut f ir st consideringwhether

it conflicted with the de finition contained in the L TD B enef it Progra m. Ifind that he did er

r but that the er

ror wa s harmless. As Judg e Cla

y no te s, the de fi nit ion

of a “ pr e -e xistin g c on dit ion ” c on ta ine d in the L TD B e ne fi t Prog ram include s lang uag e that the L TD B enef it Booklet does not; namely , the L TD B enef it Progra m inc lud e s w ith in i ts d e fi nit ion of a “ pr e -e xisti ng con di tion” a sic kn e ss o r i nju

ry “ wh e re sy

mpt oms

wer e pre sent to the deg ree that an ordina rily prudent pe rson would see k treatment.” (AR 404.) To the extent that this additional lang uag e pres ents a potential conf lict, it is irrele vant in this case, beca use it is undisput ed t h at M i t z el soug ht and re ceive d medical tre atment during the look-bac k period. The relev ant

portions of the two def

initions are substantially

alike. The ref

ore, no matter which docume nt is consulted, the outcome re mains the same, a nd the er ror wa s harmless. II. The Plan Adm inis trat or Ac ted in an Arbitrary and Capricious Mann er A. The Plan Adm inis trat or Did Not Inter pret t he P lain Meanin g of the Lan guage as ItWo uld Be Co nst r ue d by a n Or dina r y P e r so n.No. 08-4033

25 Th e second, and

mor e su bs tanti a l, i ssu e on

a pp e a l is wh e the r t

he Ma g istra

te Judg e e rr e d in finding that the P lan Admi nistrator acted i n an arbitrary and capricious manner i n denying Mitzel’s claim for long- term disability benef its. Relying on Lawson v. Forti s Insurance Co. , 301 F.3d 159 ( 3d Cir. 2002) and McLeod v. Hartford Life & Acc ident Insurance Co. , 372 F.3d 618 ( 3d Cir. 2004), the Mag istrate Judge f

ound that the Plan’s def

inition of “pre -existi ng condition” was a mbiguous. The n, applying the rule of contra proferentem and const ru i n g the ambig uity ag ainst the draf

ter, he

c on c lud e d th a t A nth e m’ s d e nia l of Mit zel ’s c la im wa s arb itr ary and c a pr ic iou s. L ike my

c oll e a g ue s, Ifind that the Mag istrate Judge e rre d in apply ing the rule of contra proferentem . T hat r ule sim ply has no application in ERI SA case s subject to an ar bitrary and ca pricious standar d of re view. Ne ve rt he le ss, lik e Judg e Cla

y , I fi nd that des pit e the e rr or in ap ply ing thi s r ule , th e Ma g istrate J udg e re ache d the rig ht result, and Anthem did ac t in an arbitra ry and ca pricious manner

in denying Mitz el’s cla im for benefits. I n ERI SA actions, t he ins urer has the burde n of provingthat an exclusion applies. See H

orton v. RelianceStandard Li fe Ins. Co. , 141 F.3d 1038, 1040 (11th Cir. 1998) . Iag ree with J udg e Clay

that Anthem has not met its burden in this case

. Iwr ite se pa

rate ly on thi s is su e on ly

be c a us e Ia m no t c on vin c e d th a t th e L TD B e ne fi t Bookle t’s definition of a “ pre- exis ting condition” is una mbiguous. The L TD B enef it Booklet def

ines

a “ p r e - e x i s t i n g c o n d i t i o n ” a s a s i c kn e s s o r

i n j u r y “for w hich y ou rec eived medical ca re or service s (including d o ct o r v i s its, prescriptions and diag nostic tests) during the three months prior to y our

e ff e c tiv e date of

c ov e ra g e .” (A R a t 35 0) (e mph a sis a dd e d. ) A s the Ma g ist rate Judg e no te d, c ourt s consideringthe same or

simil ar la ng uag e have rea ched c onflicting results, leadingto the conclusion that the def

inition i s subject to more than one interpre tation. (ROA at 347.)No. 08-4033

26 Iag ree that plan adm i n i s t ra tors are g iven leew ay in interpreting

ambig uous terms in plan documents. See Moos v. Square D. Co. , 72 F .3 d 39 , 42 (6 th Cir

. 19 95 ). Ho we ve r, that dis c re tio n is

no t c omp le te ly

un fe tte re d. “ [F ]ed e ra l c ourt s d o n ot s it in re vie w o f t he a dmi nis tr a tor ’s de c isi on s o nly for the pur

pose of r ubber stamping those decisions.” Moon v. U num Provident Corp. , 405 F.3d 373, 379 (6th Cir. 2005). Of g reat importance is the rule that, “ [i ]n i nterpre ting the pr ovisions of a plan, a plan a dminist rator must adhe re to the plain meaning of its l anguage as it woul d be construed by an ordinary person .” Sh e lby Cou nty He alt h Ca re Cor

p. v . S ou the rn Cou nc il o

f I nd us . W or k e rs H e alt h and W elfare Trust Fund , 203 F.3d 926, 934 ( 6th Cir. 2000) (emphasis adde d.) I n my op ini on , anor din ary pe rs on wo uld not construe the L TD B enef it Booklet’s de finition of a “ pre- exis ting c ondition” to include a sickne ss that w as neither diag nosed by the employ ee a

nd the employ ee’ s treatingphy sicians nor its exis tence even suspe cted dur ing the exclusionary period. The languag e “f

or which” connotes intent, and “ it is hard to se e how a doctor can provide tre atment ‘for ’ a c ondition w i t h o u t knowing w hat that condition is or that it even exists.” Lawson , 301 F.3d

a t 16 5. Whe n n e ith e r t

he patie nt n or

the ph y sic ian e ve n s us pe c ts a pa rt ic ula r i lln e ss, it i s p a te ntl y

unrea sonable to find that the patient rec eived medic al ca re or service s “for ” that condition. The ordinary Anthem employ ee is not an attorney or a ling uistician, and while the la ng uage o f t h e pree xistin g c on dit ion e xclu sio n c an be pa rs e d and de bate d in br ie fs and in c ourt room oral arg ume nts , the plan administrator is re quired by law to interpre t t h i s lang uag e “a s it would be construed by an ordinary person.” Shelby County He alth Care Corp. 203 F.3d at 934. At oral arg ument, Anthem relied heavily on the ca se of LoCoco v. Medic al Savings Insurance Co. , 530 F.3d 442 ( 6th Cir. 2008), in urg ing this court t o v ac at e the judgment below. LoCoco ,No. 08-4033

27 howeve r, is clea

rly distinguishable. I n that case , during the exclusionary period, L oCoco, a smoker , w a s a d mi tt e d

to a lo c a l e me r g e n c y r o o m c o mp la in in g o f a c o u g h an d s h o rtn e s s o f b r e a th

. A c h e s t xray reve aled a

“cloud” in his left lung. The diag nosis was pneumonia, but a CAT sc an wa s order ed beca use canc er was suspected. As Dr. Bhullar , who order ed the CAT scan, said, “[w]h en ev er y ou see something li ke [ pneumonia] in a sm oker, y ou have to follow up for c ance r of the lung .” Id. at 444. I n addition to the CAT scan, a bronchosc opy

was sug g ested. This proc edure is ordere d only when there are “ver

y strong indications” of disease. Id. Dr. Bhullar also ref err ed L oCoco to Dr. L enky , “a pulmonologist who often tre ated patients with lung ca ncer .” Id. Although L oCoco was not def initively diag nosed with lung canc er p ri or to his insurance policy ’s ef

fec tive date of

cover ag e, the insura

nce c ompany

found that he had a “ pre- exis ting condition,” i.e. , lung c ance r, and denied his c laim. This c ourt upheld that dec ision. The insurance policy at issue def

ined a “p re -e x i s ting c ondition” as “. . . a n illness . . . for which medic al advice , diag nosis, care , or t re at m en t . . . was re commended or rec eived f

rom a lice nsed hea lth practitioner during the 12 months imm ediately prec eding the e ff

ec t i ve date of cove rag e.” T his court held as follows: “[h] ere , Mr. L oCoco had a ‘pre -existi ng condition’ bec ause pr ior to the eff ective date of

cover ag e (Ma

y 29, 2002) he ha d an ‘illness’ f or which medical ‘diagnosis’ was ‘recommende d’ fr om

a do c tor . h e ill ne ss, mor e ov e r, wa s an a ilm e nt t hat wa s susp e c te d at the tim e to be , an d wa s in f a c t, lung c ance r.” Id. at 446. “Eve n though Mr . L oCoco had not re ceive d a def initive diagnosis on the eff ective date of cover ag e, diagnosis of his illness was recommende d from a doctor prior to that date. Moreove r, his undisputed medical history was hig hly

sug g estive of lungca n ce r. ” Id. I n LoCoco,

“ pr e -p oli c y

a dv ic e and

re c omm e nd a tio ns we re g ive n in this ca se ‘f or ’ lun g c anc e r be c a

us e , at the tim eNo. 08-4033

28 provided, ther e we re strongindications that Mr. L oCoco’s condition was l u n g canc er.” Id. at 448. I n sh o rt , t here was undisputed evide nce that, during the look-bac k period, L oCoco’s treating phy sicians suspecte d lung c ance r and ha d sug g ested tests t o either confirm or r ule out that particula

r dia g no sis

. I n sharp c ontrast to LoCoco , there was absolutely nothing in Mitzel’s medical history or her condition during the look-bac k period that sug g ested to any of her phy sicians the possibility that she had Weg ener ’s gra

nulomatosis. Mitz el was not diag nosed with Weg ener ’s g ranulomatosis until after the ef fec tive date of

cover ag e, and it is undisputed that, during the look-bac k period, Dr . Arsua ga, M i t z el ’s t re at i n g p h y s i ci an , n ev er ev en s u s p ec t ed t h at M i t z el h ad t h at d i s ea s e. I n fa ct , Dr

. Ar s u aga has stated: the on ly a bn or ma lity no te d wa s a ra sh and a bo rd e rl ine anti nu c le ar an tib od y sp e c kle pattern 1:80 titer. No othe r abnorm al i t y was noted to sugg est the diag nosis of Wege ner’ s g ranulomatosis. At that time she did no t m ee t the criter ia for that diag nosis. I f any

thing we were c onsidering the re mote possibili ty of sy stemic lupus ery thematosus but she did not meet enoug h criter ia either

. (A R49.) At one point, Dr. A rsuag a conside red r efe rring her to a n ear -nose- throat surg eon for a biopsy to confirm a possible diag nosis of lupus ( AR 139.) Clear ly , an ordina ry person would not find that D r. Ar su a g a

pr ov ide d M itze l w ithme dic a l c are or ser vi ces “ fo r” Weg e ne r’ s g ra nu lom a tos is during the three months prior to her ef fec tive date of

cover ag e. Th e c ri tic a l di sti nc tio n b e tw e e n th e tw o c a se s is tha t w he re a s LoCoco clea

rly involved “a suspected c ondition without a conf irmatory diag nos i s , ” t h e prese nt case clea rly involves “aNo. 08-4033

I n the former case it is not unr easona ble to de ny benef

its whe n a person is tre ated for a 1 su sp e c te d s ic kn e ss d

ur ingthe loo k- ba c k p e ri od and it i s late r c on fi rm e d b y a de fi nit ive dia g no sis

. I t is tot ally

unrea sonable, howe ver, in the latter ca se to deny benef its whe n a person is misdi ag nosed and is treated for a

n entirely differ ent sickness duringthe look-ba ck p er i o d . No ordinar y person would find that to be a reasona ble i nterpre tation of t he P lan’s definition of a pre-e x isting condition.

29 misdiagnosis or a

n unsuspected condition ma nifesting non-spec ific sy

mptoms.” LoCoco , 530 F.3d at 4 4 8 (q u o t i n g Lawson , 301 F.3d at 166). 1 I n consideringMitz el’s cl a im f o r b e n e f it s , Anth e m e mp loy ed phy sicians who simply revie wed Mitz el’s medic al re cords and g ave opinions, in hindsight, that some of the sy mptoms which Dr. Arsuag a believed wer e sy mptoms of lupus were a lso consistent with the unsuspected diag nosis of Wege ner’ s g ranulomatosis. Ba sed on these opinions, and without even ac knowledg ing the opinions of Mitzel’s treating phy sicians, Anthem dete rmined that Mitzel had rec eived medical care or service s “for ” Weg ener ’s g ranulomatosis during the look-bac k perio d , an d that the pre -existi ng condition exclusion t here fore applied. Courts have rig htly

expressed conc ern with thi s ty pe of “ afte r-the- fac t analy sis of onlynonspecific sy

mptoms.” LoCoco , 530 F.3d at 448. I n Lawson , th e Th ir d Ci rc uit no te d a s f

oll ow s: [C ]onsi deringtreatment for sy mptoms of a not-y et-diag nosed conditi on as equiva lent to treatment of the underlying c ondition ult imately diag nosed mig ht open the door f or insurance companies to de ny cover ag e for

any condition the sy

mptoms of which wer e treated during the exc l u s i o nary period. “ To permit such ba ckwa rd-looking reinter pretation of sy

mptoms t o support claims denials would so g reatly expand the definition of pre exis ting c ondition as to make that t er m m eaningless: any prior sy mptom not i nconsistent with the ultimate diag nosis wou l d provide a basis for denial.” In re Estate of Monic a Ermenc , 585 N.W.2d at 682. Lawson , 301 F.3d at 166. See also Mc Leod , 372 F.3d at 625 (“The problem with using this ty pe of

e x po st f a c to a na ly sis is that a

wh ole ho st o f s y

mpt oms oc c ur

ri ngbe fo re a

‘c or re c t’ dia g no sis isNo. 08-4033

30 rende re d , o r ev en suspected, c an pre sumably be tied to the condition once it has been dia g nosed. Thus, any time a policy

holder see ks medical c are of any kind during the look-bac k p er i od, the ‘sym p tom’ that prompted him to seek the c are could potentially be dee med a sy

mptom of a pre- exis ting condition, as l ong as i t was late r dee med consistent with sy mptoms gene rally

associate d with the condition eventually diag nosed.”)

. I ag ree with the se conce rns. Not only is this “after- thefac t” ana ly sis absolutely contra ry to how an or dinary

person would c onstrue the Plan’s de finition of a “pr e-e x isting condition,” but it is also inconsistent with t he purpose of ERI SA. Se e Fi re sto ne Tire & Rubber Co. v. Bruc h , 4 89 U. S. 1 01 , 11 3 (1 98 9) (n oti ng that Co ng re ss e na c te d E RI SA “ to p ro mot e the int e re st o f e mpl oy e e s and the ir be ne fi c iari e s in

e mpl oy e e be ne fi t pl ans and to pr ote c t c on tr a c tua lly define d benef

its.”). B. Th e P la n A dm in is t r a t o r a ls o I g no r e d a Ba s ic P r in c ip le o f C o nt r a c t La w. Ialso find that the P lan Admi nistrator’s int erpr etation of the la ng uag e “f or which you rec eived medical c are or ser

vices” is contrar

y to a basic pr i n ci p l e of contrac t law. Group be nefit plans g overne d by

ERI SA are interpre ted by the fe dera l courts using “‘g ener al rules’ of contract law as par t of the fe dera l common law.” Cassidy v. Akzo Nobel Salt, Inc. , 308 F.3d 613, 615 ( 6th Cir. 2 0 0 2 ). Under fede ral c ommon law, “ERI SA plans, like contra cts, are to be construe d as a w hole.” Alexande r v. Primeric a Holdings, Inc. , 967 F.2d 90, 93 (3d Cir.1992); Miller v. Monum ental Life Ins. Co. , 502 F.3d 1245, 1250 ( 10th Cir. 2007). Even if the “ for which” langua g e in the L TD B enef it Booklet, standing alone, is consider ed ambig uous, there is a

nother e x planation of a pre- exis ting c ondition in t he plan doc uments that doesNo. 08-4033

Whil e the e x ample re fer s to the Medical B enef it Progra m , t h at prog ram, like the L ong 2 Term Disa

bility Be nefit Prog ram, is one of seven component benef it pr og rams. See Ar

ticle 2 of the Anthem Fle x ible Be nefits Plan and Summary Plan D escr iption. Since the Plan must be c onstrued a s a wh ole , th e re is n o r e a so n w hy thi s e xamp le sh ou ld not a lso a pp ly to t he L on g Te rm

Di sa bil ity B e ne fi t Pr og ra

m. 31 not contain the wor ds “for which.” Article 7 of t he “Anthem Flexible Be nefits P lan and Summary Plan D e sc ri pti on ” re a ds a s f oll ow s: Ar tic le 7: C ir c ums tanc e s Whi c h M ay Af fe c t B e ne fi ts Your be nefits and the be nefits of y our elig ible family members will cease when your participation in the Pl an ter minates. See Ar

ticle 4 above

. Your be nefits will also cea se upon termination of the Plan. Other c ircumstance s can re s u lt in termination, reduction, or de nial of bene fits. For e xamp le , b e ne fi ts m ay

be de nie d und e r t

he me dic a l B e ne fi t Pr og ra m if you have a pre

e x ist ing c on dit ion an d in c ur

c os ts fo r tre atm e nt o

f t hat c ond ition withi n the exc lusionary period . Please consult the applica ble summary

plan desc ription, which is available on the HR intranet site, for additional information. (ROA 146) ( emphasis adde d.) 2 Th e e xamp le re qu ir e s th a t c os ts mus t be inc ur re d b y the e mpl oy e e fo r “treatme nt of that condition ” within the exclusionary period be fore there can be a denia l of bene fits. The ordinar y person c ould ea s i ly

understand that if the employ ee spe nds money for tre atment of a

known condition during the exclusionary period, a nd it later is discovere d by the P l an Admini strator that this particular c ondition ex isted befor e the e ffe ctive date of the c overa g e, the e mploy ee w ill be denied c overa g e. On the othe r hand, if, f or example, a jaundic ed employ ee suf fer ing f rom abdominal pain is diag nosed duringthe look-bac k period with g allstones and later dies of panc reatic canc er a fter the e ff e c tiv e date of

c ov e ra g e , w ou ld t

he or din ary

e mpl oy ee b e lie ve that, b e c a us e ja un dic e is aNo. 08-4033

J aundice can be a sy

mptom of pancr eatic canc er as well as g allstones. WebMD, Pa nc re ati c 3 Cancer Sym

ptoms, at htt p:/ /w ww .w e bmd .c om/ c anc e r/ pa nc re a tic -c anc e r/

pa nc re a tic -can cer -sy

mptoms (last reviewe d by L ouise Chang , MD Mar. 4, 2009) ; WebMD, Ga lls ton esSymptoms , at h tt

p : / / ww w. we b m d

. co m

/ d i ges t i v e- d i s o rd er s /t c/ gal l s t o n es-sy mp t o m s (l as t

u p d at ed Au g. 2, 2007). 32 sy mptom of both conditions, t he employ ee rec eived treatment for pancr eatic canc er during the lookback pe riod? Ithink not. I n such a case , the employ ee did not incur costs for the “tre atment of that condition ,” i.e. , pancr eatic c ance r, duringthe exclusionary period. 3 Article 7, the ref

ore, c larifies a

ny ambig uity that exis ts w ith r espec t to the de finition at issue. See Lake v. Metropolitan Life Ins. Co. , 73 F.3d 1372, 1379 (6th Cir. 1996) (finding that ambig uous lang uag e in one por

tion of an ERI SA pla

n was resolved by ref

ere nce to the clea

r and una mbiguous lang uag e in another

portion of the plan)

. III. Conclusion For the re asons s tated, under the circ umstances pr esente d here , the Plan Administrator interpre ted t he langua g e in a manner that wa s not only contra ry to the interpre tation require d by the law in this Circuit, i.e. “as it would be c o n s t ru ed by an ordina

ry person,” but also contrar y to the fede ral c ommon law requiringthat all provisions of a plan must be construed a s a whole. The Plan Administrator’s interpr etation, there fore , was a rbitrar y and ca pricious, and the judg ment o f the district court should be af firmed.