Court Opinion

ID: 26289
Source: CourtListenerOpinion
Date Created: 2010-04-25 08:50:43+00
Date Added: 2024-06-11T12:15:24.324111
License: Public Domain

IN THE UNITED STATES COURT OF APPEALS

                                   FOR THE FIFTH CIRCUIT

                                           No. 01-30788
                                         Summary Calendar

CALLIS COLLINS,

                                                                                  Plaintiff-Appellant,

                                                versus

HARLEYSVILLE LIFE INSURANCE COMPANY,

                                                                                Defendant-Appellee.

                     --------------------------------------------------------
                       Appeal from the United States District Court
                            for the Middle District of Louisiana
                                  USDC No. 99-CV-988-C
                     --------------------------------------------------------
                                        January 3, 2002
Before JOLLY, DAVIS, and STEWART, Circuit Judges:

PER CURIAM:*

       Callis Collins (Collins) appeals the district court’s summary judgment in favor of Harleysville

Life Insurance Company (Harleysville), dismissing Collins’ action under the Employee Retirement

Income Security Act (ERISA), 29 U.S.C. §§ 1001-1144, for long-term disability benefits. Collins

contends that the district court erroneously applied the wrong standard of review to Harleysville’s

denial of benefits. Alternatively, Collins contends that the district court erred in finding that

Harleysville’s plan administrator did not abuse its discretion in denying his claim.

       We review de novo the district court’s decision regarding the appropriate standard of review

to be applied to an ERISA administrator’s eligibility determination. Meditrust Fin. Servs. Corp. v.

Sterling Chems. Incorp., 168 F.3d 211, 213 (5th Cir. 1999). Unless the terms of the plan give the

       *
           Pursuant to 5TH CIR. R. 47.5, the court has determined that this opinion should not be
published and is not precedent except under the limited circumstances set forth in 5TH CIR.
R. 47.5.4.
administrator discretionary authority to determine eligibility for benefits or to construe the terms of

the plan, an administrator’s decision to deny benefits is also reviewed de novo. Id. Regardless of the

administrator’s ultimate authority to determine benefit eligibility, however, factual determinations

made by the administrator during the course of a benefits review will be rejected only upon the

showing of an abuse of discretion. Id.

       The plan administrator, Disability Management Alternatives (DMA), determined that Collins’

disability was due to a pre-existing condition that he received treatment for during the three-month

period prior to his policy’s effective date. We conclude, as did the district court, that these

determinations were more factual than interpretive in nature, and thus, the district court did not err

in applying the abuse o f discretion standard of review to DMA’s decision to deny benefits. See

Meditrust, 168 F.3d at 214; Vega v. National Life Ins. Servs., Inc., 188 F.3d 287, 295-97, 300-02

(5th Cir. 1999) (en banc).

       Collins argues that DMA abused its discretion in denying his claim because, inter alia, DMA

and its physician’s consultant labored under a conflict of interest. Collins has failed to establish a

conflict of interest on the part of DMA. See Vega, 188 F.3d at 301. Even assuming DMA’s

physician consultant did labor under a conflict of interest, Collins has failed to show that DMA abused

its discretion in denying his claim. Excluded from coverage under the Harleysville policy was a total

disability that was “caused or contributed to by or result[ed] from a pre-existing condition.” “Pre-

existing condition” is defined as a sickness or injury for which the insured received treatment within

the three-month period before the policy’s effective date. Collins admits that he sought treatment for

cervical spondylosis, a degenerative disease of the spine, in late 1997 and that he took prescription

medication for cervical spondylosis in February 1998. An October 1998, MRI noted central stenosis

affecting Collins’ C3-4, C4-5, C5-6, and C6-7 levels. Accordingly, the DMA could have rationally

concluded that the disability resulting from Collins’ diseased C4-5 level was caused or contributed

to by or resulted from Collins’ condition of cervical spondylosis for which he was treated in late 1997

                                                  2
and in February 1998. Thus, there is a rational connection between the known facts and the decision

of DMA to deny coverage. See Meditrust, 169 F.3d at 214.

       As DMA’s decision to deny coverage was not arbitrary or capricious, the district court did

not err in granting Harleysville’s summary-judgment motion. The district court’s grant of summary

judgment is therefore AFFIRMED.

                                                3