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expressing the view that while binding precedent in this circuit may favor the position of the defendant plan administrator on this issue, "the question is not settled."
Summary of this case from Cornish v. U.S. Life Insurance CompanyOpinion
Case Number 02-10204-BC
September 16, 2003
OPINION AND ORDER GRANTING DEFENDANTS MOTION TO AFFIRM ADMINISTRATOR'S DECISION AND DISMISSING CASE
The plaintiff's complaint for breach of a life insurance contract is before this Court after removal from state court on both diversity of citizenship and federal question grounds. The plaintiff's decedent, Timothy Bullard, was insured against death, including accidental death, by a policy of life insurance provided to him as part of an employee benefit plan that is governed by the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001, et seq. (ERISA). Insurancecoverage was excluded for deaths caused wholly or partially from intoxication. Timothy Bullard was killed in an automobile accident when he was driving while intoxicated, and the defendants declined to pay the death benefit to his widow, the plaintiff. The defendants have filed a motion to affirm the decision of the plan administrator. The plaintiff has not responded to the motion or filed a motion to reverse the plan administrator's decision, despite the fact that the deadlines that were established by the Case Management and Scheduling Order have come and gone. The defendants contend that the plan administrator's decision should be reviewed under the arbitrary and capricious standard, a claim that remains uncontested. Under that standard, the administrator's decision to deny benefits will be affirmed.
I.
Timothy Bullard was employed as a mechanic for Blue Lakes Charters, which provided an employee benefits plan for all eligible employees. The plan, which includes an accident insurance policy, is regulated by the ERISA and is funded by a group insurance policy issued by defendant AIG Life Insurance (AIG) through defendant Daughters of Charity National Health System, Inc. See Administrative Record (A.R.) at 13, 119. Mr. Bullard participated in the plan and named the plaintiff as a beneficiary. The accident insurance portion of the plan provides that benefits will be paid for injuries "caused by an accident occurring while this Policy is in force as to the person whose injury is the basis of claim and resulting directly and independently of all other causes in a covered loss." Id. at 24. The plan states further that "[i]f injury to the Insured Person results in death within 365 days of the date of the accident that caused the injury, the Insurance Company will pay 100% of the Principal Sum." Id. at 15. In addition, the plan lists the following exclusion from coverage: "This Policy does not cover any loss caused in whole or in part by, or resulting in whole or in part from, the following: . . . (6) the Insured Person being under the influence of drugs or intoxicants, unless taken under the advise of a Physician." Id. at 22.
On July 13, 2000, Timothy Bullard was driving his car north on Nichols Road in Montrose Township, Genesse County, Michigan when he lost control of the vehicle while attempting to pass another car, which turned left in front of him. After colliding with the other car, Bullard's vehicle crossed the centerline, left the roadway and crashed into a tree, killing Bullard and his front-seat passanger instantly. Id. at 75, 82. At the time of his death, Mr. Bullard's blood alcohol content was 0.27%, id. at 57, 71, well beyond the level of 0.10%, the point at which Michigan law presumes a driver to be under the influence of and impaired by alcohol. See Mich. Comp. Laws § 257.625.
After her husband's death, the plaintiff submitted a claim for benefits under the plan. Along with the claim, the plaintiff sent a copy of her husband's death certificate, and a copy of a newspaper article discussing the accident. Carol Leverett, the AIG claims representative assigned to the case, referred the matter to Research Service Bureau, Inc. for an investigation. A report from the research service was submitted to AIG on August 29, 2000 and included copies of police reports from the Montrose Township Police Department and the Michigan State Police, and a copy of a toxicology report from the Genesee County Medical Examiner. See id. at 53-92 The toxicology report showed that Mr. Bullard had a blood alcohol level of 0.27%. See id. at 57. After receiving the report, Leverett obtained a statement from Officer John Curtis, the Montrose Township police officer who investigated the accident, indicating that it was his opinion that Mr. Bullard's blood alcohol level of 0.27% contributed to the accident. See id. at 90.
Between October 16, 2000 and October 20, 2000, AIG conducted a claim review in which four AIG representatives participated. All four representatives agreed to deny the plaintiff's claim for benefits. On October 23, 2000, Leverett sent a letter to the plaintiff stating that AIG had denied her claim. Id. at 106. Leverett's letter stated:
In the opinion of the investigating officer, your spouse's blood alcohol level of .27 contributed to the accident. This policy excludes any loss caused in whole or in part by, or resulting in whole or in part from the Insured Person being under the influence of intoxicants; therefore no benefits are payable.Id. at 107. Leverett also informed the plaintiff that she could appeal AIG's decision in accordance with the terms and conditions of the ERISA, which govern the insurance plan. Ibid.
On November 3, 2000, the plaintiff's attorney wrote AIG a letter informing AIG that the plaintiff would appeal its decision to deny benefits. The plaintiff's attorney stated:
It was Mr. Bullard's failure to yield the right-of-way and an improper passing that caused the motor vehicle collision. Obviously, Mr. Bullard had been drinking. Your determination that this caused the motor vehicle collision is nothing more than speculation.Id. at 119. On February 7, 2001, the ERISA appeals committee met and reviewed the plaintiff's claim. In a letter dated February 12, 2001, the appeals committee issued a decision affirming the denial of the plaintiff's claim. Id. at 131.
On June 12, 2002, the plaintiff filed a complaint in the Saginaw County, Michigan Circuit Court alleging that the defendants breached the insurance contract when they denied the plaintiff's claim for benefits. On July 22, 2002, the defendants removed the case to this Court on both diversity and federal question jurisdiction grounds. The defendants alleged in the notice of removal that the life insurance policy of which the plaintiff is a beneficiary was part of an employee welfare plan as defined by the ERISA. On November 12, 2002, the Court held a case management conference with the attorneys for the parties pursuant to Federal Rule of Civil Procedure 16.At the conference, the plaintiff's counsel agreed that his claim was governed by ERISA, and the Court established appropriate deadlines to resolve the matter as such. On November 25, 2002, the Court entered an ERISA scheduling order. Pursuant to the Order, the defendants filed the administrative record with the Court, a statement regarding the appropriate standard of review, and a written notice stating whether the defendants perceived any procedural challenges in the case. The plaintiff did not file any of the statements outlined in the scheduling order. On February 11, 2003, in accordance with the scheduling order, the defendants filed a motion to affirm the decision of the plan administrator and to dismiss. The plaintiff did not file a cross motion to reverse the administrator's decision or an answer to the defendants' motion. II.
At the Rule 16 conference, the plaintiff agreed that the life insurance policy at issue in this case was part of an "employee welfare benefit plan" governed by ERISA. See 29 U.S.C. § 1002(1)(A); Pegram v. Hendrich, 530 U.S. 211, 222-23 (2000). As such, disputes over the denial of Plan benefits may be resolved by a federal court under the authority of Section 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B) ("A civil action may be brought . . . by a participant or beneficiary . . . to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.").
"[T]he validity of a claim to benefits under an ERISA plan is likely to turn on the interpretation of terms in the plan at issue." Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). In such an action, the Court generally considers only that evidence presented to the plan administrator at the time he or she determined the employee's eligibility in accordance with the Plan's terms. Smith v. Ameritech, 129 F.3d 857, 863 (6th Cir. 1997). The Court's review thus is limited to the administrative record. Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609, 615 (6th Cir. 1998). However, the Court "may consider evidence outside of the administrative record . . . if that evidence is offered in support of a procedural challenge to the administrator's decision, such as an alleged lack of due process afforded by the administrator or alleged bias on its part." Wilkins, 150 F.3d at 619.
In Firestone, the Supreme Court stated that an administrator's decision to deny benefits is reviewed under a de novo standard unless the plan provides the administrator with "discretionary authority to determine eligibility for benefits or to construe the terms of the plan." 489 U.S. at 115; see Sanford v. Harvard Industries, Inc., 262 F.3d 590, 595 (6th Cir. 2001); Wilkins, 150 F.3d at 613. "This does not mean, however, that in order to find such authority the plan must use the term `discretionary' or some other specific terminology." Hoover v. Provident Life and Acc. Ins. Co., 290 F.3d 801, 807 (6th Cir. 2002). Instead, the plan must contain "a clear grant of discretion [to the administrator]." Wulf v. Quantum Chem. Corp., 26 F.3d 1368, 1373 (6th Cir. 1994); see Perez v. Aetna Life Ins. Co., 150 F.3d 550, 555 (6th Cir. 1998) (en banc). When a plan administrator has discretionary authority to determine benefits, the court must review a decision to deny benefits under "the highly deferential arbitrary and capricious standard of review." Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 380 (6th Cir. 1996).
The insurance policy at issue here contains the following language dealing with the payment of claims:
Payment of Claims. Upon receipt of due written proof of death, payment for loss of life of an Insured Person will be made to the Insured Person's beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section of the Policy.
Upon receipt of due written proof of loss, payments for all losses, except loss of life, will be made to (or on behalf of, if applicable) the Insured Person suffering the loss.
J.A. at 23 (emphasis added). The defendants contend that this language grants to the plan administrator the discretion to decide when benefits should be paid. They cite an unpublished Sixth Circuit decision in support of their argument: Leeal v. Continental Casualty Co., No. 00-1194, 17 Fed. Appx. 341 (6th Cir. Aug. 21, 2001).
The Court believes that the binding precedent in this Circuit may favor the defendants' position, although the question is not settled. In Perez v. Aetna Life Ins. Co., the en banc court concluded that the administrator had discretion to determine eligibility and construe plan terms based on the following language: "[The administrator] shall have the right to require as part of the proof of claim satisfactory evidence . . . that [the claimant] has furnished all required proofs of such benefits." Perez, 150 F.3d at 555. The Perez court reasoned that the "plan clearly grants discretion to [the administrator] because, under the only reasonable interpretation of the language, [the administrator] retains the authority to determine whether the submitted proof of disability is satisfactory." Id. at 557. In reaching its conclusion, the court noted favorably the following cases, among others, in which discretion was found to have been vested in the ERISA plan administrator: Patterson v. Caterpillar, Inc., 70 F.3d 503, 505 (7th Cir. 1995) ("benefits will be payable only upon receipt by the Insurance Carrier or Company of . . . due proof . . . of such disability"), Caldwell v. Life Ins. Co. of North America, 959 F. Supp. 1361, 1365 (D. Kan. 1997) (benefits paid upon receipt of "due proof" that employee is disabled), and Bollenbacher v. Helena Chem. Co., 926 F. Supp. 781, 786 (N.D. Ind. 1996) (benefits paid "[w]hen the Company receives proof that the individual is disabled"). The Sixth Circuit also has held that language similar to that contained in the policy in this case does not confer a clear grant of discretion to a plan administrator. See Hoover v. Provident Life and Accident Ins. Co., 290 F.3d 801, 808 (6th Cir. 2002) (holding that the requirement that the insured submit only "written proof of loss" to the insurer, without more, did not provide a clear grant of discretion to the insurer to determine benefits or interpret the plan), and Chiera v. John Hancock Mut. Life Ins. Co., 3 Fed. Appx. 384, 390 (6th Cir. 2001) (unpublished) (holding that the requirement that the insurer be provided with "written proof of loss" does not explicitly grant the insurer discretionary authority).Other Circuits are divided on the question. Compare Herzberger v. Standard Ins. Co. , 205 F.3d 327, 331-32 (7th Cir. 2000) (holding that "the presumption of plenary review is not rebutted by the plan's stating merely that benefits will be paid only if the plan administrator determines they are due, or only if the applicant submits satisfactory proof of his entitlement to them;" instead, the court reasoned that a requirement that a plan participant provide "proof or satisfactory proof" of a disability does not "give the employee adequate notice that the plan administrator is to make a judgment largely insulated from judicial review by reason of being discretionary" and, therefore, the court did not apply an arbitrary and capricious standard in reviewing the plan administrator's decisions), and Kinstler v. First Reliance Standard Life Ins. Co. , 181 F.3d 243, 252 (2d Cir. 1999) (holding that "unless a policy makes it explicit that the proof must be satisfactory to the decision-maker , the better reading of "satisfactory proof" [language in a plan] is that it establishes an objective standard, rather than a subjective one"), with Nance v. Sun Life Assur. Co. of Canada , 294 F.3d 1263, 1268 (10th Cir. 2002) (holding that the "satisfactory to Sun Life" language in the plan was sufficient to convey discretion to Sun Life in finding the facts relating to disability), and Snow v. Standard Ins. Co. , 87 F.3d 327, 330 (9th Cir. 1996) (holding that a plan requiring "satisfactory written proof of claimed loss" confers discretion to determine eligibility for benefits).
The plaintiff, however, has not taken issue with the defendants' argument that the deferential standard of review applies, and the Court will, therefore, apply it. When applying the arbitrary and capricious standard, the Court must determine whether the administrator's decision was reasonable in light of the available evidence. Put another way, if there is a reasonable explanation for the administrator's decision in light of the plan's provisions, then the decision was not arbitrary and capricious. Williams v. Int'l Paper Co., 227 F.3d 706, 712 (6th Cir. 2000); Smith v. Ameritech, 129 F.3d 857, 863 (6th Cir. 1997). See also Abbott v. Pipefitters Local Union No. 522 Hosp., Medical, and Life Benefit Plan, 94 F.3d 236, 240 (6th Cir. 1996), cert. denied, 519 U.S. 1111 (1997) (holding that the arbitrary and capricious standard is the least demanding form of judicial review of administrative action).
In this case, the plaintiff admits that her husband had been drinking, but contends that AIG's determination that the drinking caused the car accident is nothing more than speculation. The defendants argue that AIG took intoconsideration several factors regarding Mr. Bullard's death before denying the plaintiff benefits. For example, AIG obtained the toxicology report showing that Mr. Bullard had a blood alcohol level of .27%, secured the opinion of Officer Curtis who stated that Mr. Bullard's intoxication was a contributing cause of the fatal accident, and obtained the police reports detailing the accident facts. Thus, the defendants contend that AIG relied on ample evidence in making the determination that intoxication was, wholly or in part, a contributing cause of Mr. Bullard's automobile accident and, consequently, AIG properly denied the plaintiff's claim for benefits under the accident insurance policy.
The Court agrees. Under a deferential standard of review, the Court cannot say that the plan administrator's decision was not supported by substantial evidence. The plan administrator's decision was reasonable in light of the available evidence on the administrative record and the plan provisions.
III.
The Court determines that the plan administrator did not arbitrarily deny the plaintiff's claim for the death benefit on her husband's insurance policy.
Accordingly, it is ORDERED that the defendants'motion to affirm the administrative decision and to dismiss [dkt # 15] is GRANTED.
It is further ORDERED that the plaintiff's complaint is DISMISSED WITH PREJUDICE.