Opinion
Case No. 02-4089-JAR
March 10, 2004
ORDER DENYING WITHOUT PREJUDICE DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
Plaintiffs, the widow and surviving children of Thomas E. Cowser, bring suit pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et. seq., to recover benefits of an Accidental Death and Dismemberment Policy administered by defendant, American United Life Insurance Company. Defendant has denied that the accidental death benefits are payable to Plaintiff's because Mr. Cowser's motorcycle wreck was not an "accident" as defined in the policy and that an exclusion involving the use of illegal drugs bars payment.
This matter is before the Court on defendant's Motion for Summary Judgment (Doc. 7). For the reasons set forth below, defendant's motion is denied without prejudice.
In Firestone Tire Rubber Co. v. Bruch, the Supreme Court wrote that a denial of benefits challenged under § 1132 "is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." If the plan grants discretionary authority to the administrator or fiduciary, the exercise of that authority will be set aside only if it is arbitrary or capricious.
489 U.S. 101, 115 (1989).
Nance v. Sun Life Assurance Company of Canada, 294 F.3d 1263, 1266 (10th Cir. 2002) (citation omitted).
In applying Firestone, it is essential to focus precisely on what decision is at issue, because a plan may grant the administrator discretion to make some decisions but not others. In Nance v. Sun Life Assurance Company of Canada, the Tenth Circuit clarified what language confers discretion on a plan administrator. Plaintiff's challenge two decisions by defendant in denying them benefits. First, they contend that defendant misconstrued the Plan when it decided his death was not "accidental" because he had allegedly been drinking at the time of the crash. Second, they contend that defendant erred in its factual decision that Mr. Cowser had used illegal drugs at the time of his accident. Unfortunately, the parties fail to address the standard of review applicable to either question.
Id.
Further, in the event a de novo standard is appropriate, Plaintiff's attempt to offer additional evidence that defendant contends was outside the administrative record, including records regarding his drug treatment for Hepatitis C, the fact that Mr. Cowser had been administered opiates upon admission to the hospital, and the administration of Haldol and the resulting seizure that may or may not have contributed to his death. The Court's analysis of this issue is hindered by a lack of administrative record. Although defendant attaches the Certificate of Death, accident report and other medical documents, it does not include any findings or reasoning of the plan administrator in denying plaintiffs' claims. Further, Plaintiff's fail to explain or discuss why these additional extra-record materials should be considered by this Court under the factors set forth in Hall v. Unum Life Ins. Co. of America.
300 F.3d 1197 (1011 Cir. 2002). These exceptional circumstances include claims that require consideration of complex medical questions or issues regarding the credibility of medical experts; the availability of very limited administrative review procedures with little or no evidentiary record, etc. Id. at 1203.
In light of the insufficiencies in both parties' memoranda, the Court shall deny the defendant's motion without prejudice to refile to address the issues discussed above. Defendant's motions shall be due on or before 30 days from the date of this order, or April 9, 2004 . Plaintiffs' response shall be due 20 days thereafter, and defendant's reply shall be due 20 days from the date of Plaintiff's response.
D. Kan. Rule 6.1(e)(2).
IT IS SO ORDERED.