December 23, 2011 (PLANSPONSOR.com) – A federal district court found the National Football League’s pension plan board was following plan rules when it denied disability benefits to a former player.
U.S. District Judge Richard W. Story of the U.S. District Court for the Northern District of Georgia noted the terms of the Bert Bell/Pete Rozelle NFL Player Retirement Plan say if the voting members of the board are deadlocked on whether a player meets the requirements for disability benefits, the plan provides that it may submit that medical questions to a medical advisory physician (MAP) for a final and binding determination. Story found that once the board refers the medical question to an MAP, it is prohibited from relying on the opinions of other physicians in deciding whether to grant or deny benefits.
According to the court opinion, the plan states the MAP is granted “full and absolute discretion, authority and power” to decide whether the claimant satisfies the threshold disability requirements for receipt of benefits. “Accordingly, so long as the MAP’s conclusions are reached in accordance with the AMA [American Medical Association] Guides, the Board is required under the terms of the Plan to accept those conclusions,” Story wrote.
The court previously determined the board has discretion in interpreting and applying the terms of the plan, and the board was not operating under a conflict of interest.
Willie Grant appealed the denial of line-of-duty (“LOD”) disability benefits provided under the plan, which states any player who incurs a “substantial disablement,” defined as that which results in a 25% whole person impairment (WPI).
Grant was referred by the plan to a docotor for a medical evaluation. The doctor determined Grant had a WPI of 9%, which failed to meet the threshold requirements for receipt of LOD benefits, so the disability committee denied Grant’s claim for benefits.
Shortly after submitting an appeal to the retirement plan board, Grant retained and was examined by two different physicians who gave him a WPI of 32% and 25%, respectively. The board asked its medical director to comment on the ratings of the physicians, and the medical director said he could not reconcile the ratings, but the inconsistencies should be resolved through an evaluation by an MAP. The MAP evaluated Grant and ultimately concluded that he had a WPI rating of 24%, still short of the plan’s requirements. The case is Grant v. Bert Bell/Pete Rozelle NFL Player Retirement Plan, N.D. Ga., No. 1:09-cv-01848.