United States District Court, N.D. Texas, Dallas Division
MEMORANDUM OPINION AND ORDER
A. FITZWATER UNITED STATES DISTRICT JUDGE
Charlize Marie Baker (“Baker”)-who is undergoing
the process of gender transition from male to female-sues
defendant Aetna Life Insurance Company (“Aetna”),
seeking to recover short-term disability benefits under an
ERISA-qualified short-term disability benefits
plan (“STD Plan”) following breast augmentation
surgery. Following a bench hearing, and for the reasons that
follow, the court holds that Aetna gave a legally correct
interpretation to the STD Plan and did not abuse its
discretion in denying Baker's claim. The court therefore
enters judgment in favor of Aetna.
is an employee of L-3 Communications Integrated Systems, LP
(“L-3”) and a participant in the company's
ERISA-qualified health benefits plan (“Health
Plan”) and STD Plan. Aetna is the third-party
administrator of the Health Plan and the claim fiduciary and
administrator of the STD Plan.
Baker began the process of gender transition from male to
female. Baker was advised during her transition by Feleshia
Porter, M.S., L.P.C. (“Porter”), a licensed
professional counselor. As part of Baker's gender
transition, she underwent hormone replacement therapy, which
was covered under the Health Plan. Baker developed size B-C
breasts as a result of hormone replacement therapy. In 2015,
after consulting with Porter, Baker underwent breast
augmentation surgery (i.e., implant surgery). Baker sought
benefits from Aetna under the STD Plan for her post-surgery
considering Baker's claim, Aetna relied on her medical
records, including records from her plastic surgeon, Scott
Harris, M.D. (“Dr. Harris”), and Baker's own
disclosures in the claim documentation. Dr. Harris'
records described the surgery as a breast augmentation. And
on the Aetna claim form, Baker answered the question,
“What is the primary medical condition that keeps you
from working?” with the response, “cosmetic
procedure.” P. App. 5. Aetna denied Baker's claim
on the ground that her surgery was not caused by an illness,
injury, or pregnancy-related condition, as required for
coverage under the STD plan. Aetna informed Baker by letter
and telephone call of the denial. Aetna's letter also
informed Baker of her right to appeal the decision, and to
submit additional documents and records.
appealed Aetna's initial denial.
submitted two letters in support of her appeal. The first,
from Dr. Harris, stated that “[t]his surgery was for a
breast reconstruction for her transgender surgery that she
was interested in having done. Transgender surgery, as you
know, has become a functional indication for surgery.”
P. App. 83. The second letter, from Porter, stated:
Charlize Baker has been going through gender transition[.] .
. . Therapeutic issues we have addressed include family; self
esteem; motivation for physical alterations; and permanent
effects of gender transition. In March of this year my client
received her first medically necessary surgery. Breast
augmentation is considered reconstructive and necessary in
Id. at 84.
denied Baker's appeal, once again finding that the
surgery did not meet the plan criteria of being medically
necessary and due to an illness, injury or pregnancy-related
condition. In its letter informing Baker of the appeal
decision, Aetna wrote that all information in the claim file
had been considered, including the letters from Porter and
Dr. Harris. Aetna stated that, although it was aware that
Baker had been undergoing gender transition since 2011, Baker
had continued working during that time, and the evidence did
not establish that her breast augmentation surgery was
medically necessary and due to an illness.
filed this lawsuit against Aetna and L-3. In a prior
memorandum opinion and order, Baker v. Aetna Life Ins.
Co., ___ F.Supp.3d ___, 2017 WL 131658 (N.D. Tex. Jan.
13, 2017) (Fitzwater, J.), the court dismissed Baker's
discrimination claim against Aetna and L-3 under § 1557
of the Patient Protection and Affordable Care Act,
id. at *4; dismissed Baker's alternative
ERISA-based discrimination claim, id.; dismissed
Baker's claim against Aetna for sex/gender
discrimination, in violation of Title VII of the Civil Rights
Act of 1964 (“Title VII”), 42 U.S.C. § 2000e
et seq., id. at *5; and denied L-3's
motion to dismiss Baker's Title VII claim, id.
Baker's ERISA claim (other than the alternative
discrimination claim) against Aetna and her Title VII claim
against L-3 remain for adjudication. Id. The court
today addresses Baker's ERISA claim against Aetna.
ERISA plan participant who is denied benefits can sue to
recover them. See 29 U.S.C. § 1132(a)(1)(B).
This court has jurisdiction to review determinations made by
an ERISA employee benefit plan. See, e.g., Vega v.
Nat'l Life Ins. Servs., Inc., 188 F.3d 287, 295 (5th
Cir. 1999) (en banc), overruled on other grounds by
Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 119 (2008).
In conducting this review, the
plan administrator's factual determinations are always
reviewed for abuse of discretion; but its construction of the
meaning of plan terms or plan benefit entitlement provisions
is reviewed de novo unless there is an express grant
of discretionary authority in that respect, and if there is
such then review of these decisions is also for abuse of
Vercher v. Alexander & Alexander Inc., 379 F.3d
222, 226 (5th Cir. 2004). In this case, the parties agree
that the STD Plan grants Aetna discretionary authority to
construe the plan's terms. Accordingly, review of
Aetna's construction of the meaning of plan terms or plan