Opinion ID: 168783
Heading Depth: 3
Heading Rank: 2

Heading: Is the Plan’s Language Ambiguous?

Text: Under even the most exacting standard of review , Blue Cross’s decision to deny Hollingshead’s claim must be affirmed because of the Plan’s unambiguous terms. W e have held that where an employee benefit plan’s written terms unambiguously govern what benefits are due “under the terms of the plan,” 29 U.S.C. § 1132(a)(1)(B), they are determinative as a matter of law. Admin. Com m . of the Wal-M art Assocs. Health & Welfare Plan v. Willard, 393 F.3d 1119, 1123 (10th Cir. 2004) (“In interpreting an ERISA plan, the court examines the plan -7- documents as a whole and, if unambiguous, construes them as a matter of law.”). In this case, if the Plan’s terms clearly, plainly, and conspicuously dictate a certain outcome, Blue Cross could not be arbitrary and capricious in following that direction. In reviewing the terms of the Plan, we find no ambiguity in its organ transplant provisions. “Ambiguity exists w hen a plan provision is reasonably susceptible to more than one meaning, or where there is uncertainty as to the meaning of the term.” Willard, 393 F.3d at 1123 (quotation omitted). In construing the terms of an ERISA plan, language is given “its common and ordinary meaning as a reasonable person in the position of the [plan] participant, not the actual participant, would have understood the words to mean.” Id. The Plan provides, in relevant part, c. Liver Transplants. Benefits will be provided for a liver transplant, provided the Subscriber: 1) has end-stage liver disease with a life expectancy of 18 months or less due to any of the following conditions: . . . c) primary scherosing cholangitis; . . . 2) has normal kidney function; 3) has no concurrent extrahepatic malignancy (including extrahepatic extension or primary hepatocellular carcinoma, HIV infection or AIDS; and 4) is psychologically stable and has a supportive social environment.