Booth v. Wal-Mart Stores, Inc., 201 F.3d 335 (4^th Cir. 2000)-This case involves a suit for wrongful denial of benefits under 29 U.S.C. § 1132(a)(1)(B).  Following a cardiac catheterization with coronary angiography and a coronary angioplasty to clear a 75% blockage in her right coronary artery, Booth filed a claim for reimbursement of her expenses under her employee benefit plan.  Booth had enrolled four months earlier in the plan.  The plan administrator denied the claim under the plan's preexisting condition exclusion.  (The plan stated:  “Any charges with respect to any participant for any illness, injury, or symptom (including secondary conditions and complications) which was medically documented as existing, or for which medical treatment, medical service, prescriptions or other medical expense was incurred within 12 months preceding the effective date of these benefits as to that participant, shall be considered pre-existing)”.

Booth admitted she had been previously treated for high blood pressure and cholesterol, but her general physician stated he found no evidence of preexisting coronary artery disease.  The Plan’s reviewing doctor made similar findings regarding Booth’s hypertension, except that he added his suspicion that Booth’s physicians had "treated" for her coronary artery disease, based on her prescription for Cardizem.[1]  Another reviewing doctor that the Plan hired suggested preexisting coronary artery disease based on what was later alleged by Booth’s doctor to be a misunderstanding of the abbreviation "HCVD" as referring to coronary vascular disease rather than cardiovascular disease (commonly understood to refer simply to hypertension.)  Booth then forwarded a letter from yet another doctor to the Plan stating that Booth was neither treated for nor diagnosed as having coronary artery disease or angina during the period in question.

Rather than sort through the conflicting medical opinions, this court turned to the question of standard of review, and found that the Plan’s decision was principled and reasoned, and the evidence before it supported its conclusions.  Although courts generally review ERISA plan decisions de novo, when a plan by its terms confers discretion on a fiduciary and the fiduciary acts within the scope of conferred discretion, the abuse of discretion standard is appropriate.  (The court took the opportunity in this decision to clarify ambiguity in the case law about whether the proper standard is "abuse of discretion" or "arbitrary and capricious," the latter being the more deferential standard.)

This court cited the broad exclusion language for preexisting conditions and pointed out that in Elliott v. Sara Lee Corp., 190 F.3d 601, 606 (4^th Cir. 1999) (citing Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 234 (4^th Cir. 1997), it stated that "it is not an abuse of discretion for a plan fiduciary to deny ... benefits where conflicting medical reports were presented."  The Plan administrator is entitled to resolve conflicts in the medical record to make a decision regarding benefits.