Opinion
Case No. 1:04CV107DAK.
April 18, 2005
MEMORANDUM DECISION AND ORDER
This matter is before the court on Plaintiffs Boyd Lemon, Betty Lemon and Corey Lemon's Motion for Summary Judgment and Defendant E.A. Miller's Motion for Summary Judgment. The court held a hearing on these motions on March 31, 2005. Plaintiffs were represented by Herm Olsen and Gary N. Anderson and Defendant was represented by Scott A. Hagen. The court took the motions under advisement. The court has carefully considered all pleadings, memoranda, and other materials submitted by the parties. The court has further considered the law and facts relevant to the parties' motions. Now being fully advised, the court enters the following Order.
BACKGROUND
This is an ERISA action regarding the denial of medical benefits under Defendant E.A. Miller's Medical Reimbursement Plan ("the Plan"). The Plan is an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974, as amended ("ERISA").
Boyd Lemon has been employed by Defendant E.A. Miller for over twenty years and was a participant in the Plan at all times relevant to this action. His son, Corey Lemon, who was a beneficiary under the Plan, was severely injured in a car accident when another car struck the car he was driving on the driver's side. Corey was extricated from his vehicle with the jaws of life and transported to Logan Regional Hospital. He was then life-flighted to LDS Hospital, where he remained comatose for several weeks. Corey suffered a permanent brain injury. The Lemons have incurred significant medical bills as a result of the accident and have mortgaged their home to pay for the bills.
The emergency medical technician ("EMT") who responded to the scene of the accident noted in his report of the accident that Corey was not wearing a seatbelt. The life-flight records and hospital records relied on the EMT report and also indicated that no seatbelt had been used. Defendant claims that based on these documents, Kristen Campbell, E.A. Miller's Health Benefits Administrator, notified the Lemons, in a letter dated May 11, 1999, that any claims resulting from the accident would not be covered. However, the letter itself notifying the Lemons of the denial did not identify any information Ms. Campbell was relying on to deny the claim.
The letter quoted Defendant's policy which provides that no benefit will be provided for "expense incurred for hospitalization or other medical care provided as a result of injuries sustained . . . in any incident involving a motorized vehicle where the injured participant was driving or was a passenger in such vehicle and was not wearing a seatbelt." The letter further notified Plaintiffs that they could appeal the decision by sending a written appeal with any additional information or comments to the appeals committee within 60 days.
On June 15, 1999, Boyd Lemon appealed the denial of benefits by filing a "Customer Relations Complaint Form" and attaching a letter to the form. The form indicated that Debi Bentley was a witness to the accident and provided her telephone number. And, the attached letter states,
How can you determined [sic] that your children will wear their seat belt when you are not with them. We tell our children how important it is to wear a seat belt, but there is no guarantee they will wear them. The people at the scene of the accident feel that a seat belt would not of helped Corey from getting hurt worse. The impact was on his side. The door and steering wheel was pushed to the passenger's side. The dash board was ripped in half. If Corey had stayed in place, he would of been crushed or killed. They had to use the jars [sic] of life to get the door off to get Corey out. Enclosed are pictures of the wrecked car. People say the car looked worse than the pictures. Seat belts saved 99% of the time, but witnesses believe that Corey's accident is the 1% that seat belts would not of helped.
On July 9, 1999, Paul Barnard, Defendant's Human Resource Director, responded to Mr. Lemon. The letter stated that the Employee Benefits Committee had considered his appeal and, although it was sympathetic to the situation, the Plan's guidelines regarding seat belt usage were specific and had to be adhered to for reimbursement. Therefore, the letter notified Mr. Lemon that his appeal was denied. However, once again, there was no indication in the letter what evidence Defendant had considered in making its determination.
Plaintiffs filed the instant action on July 20, 2004. In connection with Plaintiff's motion for summary judgment, Plaintiffs have supplied affidavits from several new witnesses to the accident. Debi Bentley, who was the first on the scene, states: "I ran up to the driver's side window and witnessed that Corey Lemon was still wearing his seatbelt. I know this because I was the first on the accident scene. I do know that he had on his seatbelt. I told that to the police personnel that showed up at the scene." Billie J. Sessions also stated: "I am virtually certain that the driver was wearing his seatbelt. I have a visual recollection of seeing the buckled seatbelt." And, a third witness, Janine Lilenquist, stated: "I do remember seeing a seatbelt on Corey Lemon, but I did not spend a lot of time with him as I was trying to take case of the other young man."
In addition, Randy Craner, the Emergency Medical Technician who responded to the accident and stated in his report that a seat belt was not used, provided an additional affidavit stating, "I was not the first individual on the scene. There were several other people providing assistance when I arrived and giving aid as they could. At the time I administered aid and gave assistance to Mr. Lemon, he did not have his seat belt on. Because of multiple people who preceded me at the scene, I cannot say whether someone had detached Mr. Lemon's seat belt or not. I cannot say whether or not Mr. Lemon was wearing his seat belt at the time of impact." Furthermore, Police Officer Bob Mouritsen investigated the collision and stated on the police report that a seatbelt was used. The number one was used on the report under safety equipment which indicates that a lap belt was used.
DISCUSSION
Defendant argues that Plaintiffs' state law claims are preempted by ERISA, that the ERISA claims should be dismissed because they are barred by the statute of limitations, and there is no evidence that the administrator's decision was arbitrary and capricious. Plaintiffs do not dispute that their state law claims are not preempted. However, Plaintiffs do dispute whether their claims are timely, the proper standard of review this court should use in reviewing the matter, and whether the plan administrator's decision should be reversed based on the investigation conducted by the plan administrator.
Therefore, the issues presented by this case are: (1) whether the applicable statute of limitations to this action is Utah's three-year statute relating to insurance contracts or the six-year statute relating to written contracts; (2) the appropriate standard of review given the discretion provided in the Plan and potential conflicts of interest that are present; and (3) whether the Plan's denial of benefits was correct under the appropriate standard of review.
I. Preemption
Defendant moves to dismiss Plaintiffs' state law claims for breach of contract, breach of the implied covenant of good faith and fair dealing, and subrogation on the ground that they are preempted by ERISA. Plaintiffs did not oppose Defendant's motion in this respect. Therefore, Plaintiffs' common law claims are preempted by ERISA and should be recast as claims under ERISA.
II. Statute of Limitations
Next, Defendant moves to dismiss Plaintiff's claims as time barred under Utah's three year statute of limitation for an action based on an insurance contract. ERISA does not specify a limitation period for claims brought under 29 U.S.C. § 1132(a)(1)(B). Instead, the state statute of limitations that is most analogous to the claim at issue applies. Lang v. Aetna Life Ins. Co., 196 F.3d 1102, 1104 (10th Cir. 1999). Because this case was instituted five years after Defendant denied Plaintiff's claim, the main dispute is whether Utah's three-year insurance contract statute of limitations or the six-year written contract statute of limitations applies.
Defendant relies on the Tenth Circuit's decision in Lang. In Lang, the plaintiff sought to recover benefits which she had been denied by Aetna, and the court held that the most analogous Utah statute of limitation was the three-year statute applicable to actions on a written policy or contract of first party insurance. Id. (citing Utah Code Ann. § 31A-21-313(1) ("An action on a written policy or contract of first party insurance must be commenced within three years after the inception of the loss.")).
Plaintiffs rely on Judge Cassell's decision in Kerry v. Southwire Co. Affiliates Employee Benefit Plan, 324 F. Supp. 2d 1225 (D. Utah 2004). Judge Cassell acknowledged the ruling in Lang, but distinguished between an ERISA plan funded through a group insurance policy and a self-funded ERISA plan, following the Eighth Circuit's opinion in Harris v. The Epoch Group, L.C., 357 F.3d 822, 827 (8th Cir. 2004). In analyzing whether the self-funded nature of an ERISA plan should make a difference with respect to the statute of limitations to be applied, Judge Cassell referenced Utah's comprehensive insurance code which states that it does not cover "self-insurance." 324 F. Supp. 2d at 1229 (citing Utah Code § 31A-1-103, § 31A-1-301(142)). Judge Cassell also reasoned that where there was no group policy insurer involved it was essentially a contract action between and employee and his or her employer, which should be governed under the general written contract statute of limitations. Id. Finally, Judge Cassell recognized that the express purpose of ERISA is to ensure and protect employees from losing their promised benefits. Pursuant to such policy dictates, courts have adopted the statute of limitations governing contract actions because they are generally favorable to plaintiffs. Id. The court then ruled that Utah's six-year statute of limitation for breach of a written contract was the most analogous statute of limitation. Id.
Defendant asserts that Kerry improperly assumes that the minimal differences between a self-funded plan and a group insurance plan justify a dramatic difference in limitations periods. Defendant contends that although self-funded medical plans are not technically insurance policies, they operate in substantially the same manner as group insurance policies. The only difference is that the risk is borne by the plan sponsor instead of an insurance carrier.
However, the court agrees with Judge Cassell's reasoning. Although there are similarities between group insurance plans and self-funded plans, Utah's Insurance Code makes a distinction between such plans when it provides that it does not apply to "self-insurance." In addition, an employer with a self-funded plan has agreed to bear the risks. Therefore, a dispute under a self-funded plan is essentially a contract dispute between an employer and an employee. And, this court must recognize that, to the extent that the self-funded plan is governed by ERISA, the express intention of Congress in passing the act was to protect the interests of employees from unjustly losing their benefits. Therefore, this court also finds that the most analogous state statute is the six-year statute of limitations for actions on a written contract. Accordingly, Defendants' motion for summary judgment on these grounds is denied.
III. Standard of Review
The parties dispute whether the case should be reviewed under a de novo standard or the arbitrary and capricious standard. ERISA itself does not specify the standard of review that should be used. However, the United States Supreme Court has held that a denial of benefits challenged under ERISA, "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." Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). When the plan grants discretionary authority to the administrator, the denial of benefits is reviewed under the "arbitrary and capricious" standard. Chambers v. Family Health Corp., 100 F.3d 818, 825 (10th Cir. 1996).
Plaintiffs cite to a section of the Plan indicating that participants have the right to appeal their decision to federal court if they are not satisfied with the result to assert that there is not discretion. However, the Plan states that the Plan Administrator "has all discretionary authority to interpret the provisions and control the operation and administration of the Plan within the limits of the law. All decisions made by the Plan Administrator shall be final and binding on all parties." This language clearly gives the Plan Administrator discretion. Therefore, the main dispute between the parties focuses on whether there is a conflict of interest and, if so, how that conflict affects the standard of review.
Plaintiff also argues that because this language does not appear in the Summary Plan Description, there is a conflict between the terms of the Plan and the SPD. However, there is no requirement that everything in the Plan must be contained in the SPD. The discretionary language need only be in the Plan or the SPD. Moreover, there is no conflict merely because one document contains the language and one does not.
Under Tenth Circuit law, "if a plan gives discretion to an administrator or fiduciary who is operating under a conflict of interest, that conflict must be weighed as a factor in determining whether there is an abuse of discretion." Fought v. Unum Life Insurance Co. of America, 379 F.3d 997, 1003 (10th Cir. 2004). Under the Tenth Circuit's "sliding scale" approach, the reviewing court applies the arbitrary and capricious standard of review, however, because the standard is inherently flexible, "the court must decrease the level of deference given to the conflicted administrator's decision in proportion to the seriousness of the conflict." Id. at 1004.
The degree of deference given to the Plan Administrator depends upon whether the Plaintiff has established a "standard conflict of interest" or an "inherent conflict of interest." Id. at 1004. A "standard" conflict of interest exists where the plan administrator is employed by a company with a self-funded plan and "the company's profit is not derived solely from its administration of the health benefits plan." Pitman v. Blue Cross Blue Shield, 217 F.3d 1291, 1296 n. 4 (10th Cir. 2000). An "inherent" conflict of interest exists if the company is an insurance company with no means other than its insurance business to generate income and there is a conflict between its discretion in paying claims and its need to stay financially sound. Id.
Under the facts of this case, only a "standard" conflict of interest could be established. It is undisputed that the claim was initially reviewed and decided by one of the President's delegates, the Benefits Administrator, Kristen Campbell. The Employee Benefits Committee then reviewed and upheld the decision to deny benefits. Ms. Campbell and the members of the Employee Benefits Committee are all employees of Defendant E.A. Miller.
A plaintiff cannot establish a conflict of interest based on the mere fact that the plan administrator is a company employee. Fought, 379 F.3d at 1005. To determine whether a standard conflict of interest is present, a court should consider the following factors, including whether: "(1) the plan is self-funded; (2) the company funding the plan appointed and compensated the plan administrator; (3) the plan administrator's performance reviews or level of compensation were linked to the denial of benefits; and (4) the provision of benefits had a significant economic impact on the company administering the plan." Id. It is Plaintiffs' burden to establish the existence and nature of the conflict of interest. Id. at 1003.
Plaintiffs argue that the clear conflict of interest in this case is that the Plan Administrator of the self-funded plan is also the president of the company. Since the plan is self-funded, any money paid for claims comes out of the profits of the company. While these facts demonstrate at least some conflict of interest was present, Plaintiffs have not shown that the plan administrator's level of compensation or performance reviews were linked to the denial of benefits or that the provision of benefits would have had a significant economic impact on E.A. Miller. Therefore, the seriousness of the conflict based on these factors does not appear substantial.
However, "[a] conflict of interest can arise between a plan administrator's duty to act `solely in the interest of the participants and beneficiaries' of the plan, 29 U.S.C. § 1104(a)(1), and his self interest or loyalty to his employer." Kimber v. Thiokol Corp., 196 F.3d 1092, 1097 (10th Cir. 1999). In Kimber, the Tenth Circuit recognized that a court should give less deference when the plan administrator failed to gather or examine relevant evidence. Id. Plaintiffs argue that the deficient investigation conducted by the plan administrator in this case indicates that there was a conflict of interest because the company did not want to discover anything that would contradict the EMT's report stating that no seat belt was used. Plaintiffs point to the fact that Mr. Lemon stated in his appeal that Debi Bentley was a witness and provided her telephone number but nobody ever contacted her in their consideration of the appeal. In addition, none of the witnesses to the accident or occupants of the cars were ever contacted, the EMT who prepared the report was not interviewed, nor was the police report reviewed.
The court finds that Defendant's failure to adequately investigate the factual basis for applying the seat belt exclusion demonstrates that the investigation may have been tainted by self-interest for the company and that a full and fair review was not conducted. The May 11, 1999 letter from Kristen Campbell to Mr. Lemon denying coverage failed to identify any evidence the Plan relied upon to make its decision. It simply stated that no seat belt was being worn and coverage was being denied under an exclusion in the Plan. The letter states that the decision was made "based on the information provided to our office." However, it does not state what the information was or who provided the information. The letter also came only five days after the accident and there is no indication that the Lemons had even filed a claim under the Plan. The letter states that the Plan had been notified by some unidentified entity that an accident had occurred and any claims resulting from the accident would be denied. Because the letter did not notify Plaintiffs of the factual basis for denial, they had no information regarding what type of additional information they would need to provide for an appeal of the decision.
Before this court, Ms. Campbell has provided an affidavit stating that she relied on medical records from the hospital and the EMT report from the ambulance to make her decision. Plaintiffs never had the benefit of knowing that the decision was based only on these documents. If Plaintiffs had been notified that Defendant had not conducted any kind of investigation into what had occurred at the scene, they would have been able to conduct their own investigation and provide additional information. As it happened, the Plaintiffs were not given sufficient information upon which to proceed. A plan administrator, as a fiduciary under the Plan, has an obligation to provide participants with sufficient information from which they can proceed through the claims process.
Because the plan is self-funded, the plan administrator was an employee of the company, the plan administrator failed to investigate the factual basis for denial of the claim, and the plan administrator failed to give Plaintiffs adequate notice of the evidence she was relying upon to make her decision in the denial letter, the court concludes that the level of deference should be considerably decreased.
IV. Additional Evidence Review of Determination
The parties dispute whether this court can consider the evidence and arguments submitted by Plaintiffs that Corey was wearing a seatbelt because the arguments and evidence were not submitted to or before the Plan Administrator. Several Tenth Circuit cases state that in reviewing a plan administrator's decision under the arbitrary and capricious standard, federal courts may consider only the arguments and evidence that were before the administrator at the time it made its decision. See, e.g., Sandoval v. Aetna Life Insur. Co., 967 F.2d 377, 380 (10th Cir. 1992).
However, the Tenth Circuit allows new evidence to be admitted under the de novo standard of review in certain limited circumstances. Hall v. UNUM Life Ins. Co. of Am., 300 F.3d 1197, 1203 (10th Cir. 2002). Recognizing the infinite variety of ERISA cases that are brought in federal court and the fact that some cases may arrive with very limited records and may involve plans in which the payor and administrator are one and the same, the Tenth Circuit determined that providing district courts with flexibility to admit additional evidence in limited circumstances is appropriate and even necessary in order to address the varied situations in which the administrative record alone may be insufficient to provide a proper de novo review. Id.
To provide guidance to district courts on this issue, the Tenth Circuit noted that "the following exceptional circumstances could warrant the admission of additional evidence: . . . the availability of very limited administrative review procedures with little or no evidentiary record; . . . instances where the payor and the administrator are the same entity and the court is concerned about impartiality; . . . and circumstances in which there is additional evidence that the claimant could not have presented in the administrative process." Id.
Because the Plan at issue in this case provides discretion, this court must apply the arbitrary and capricious standard of review. However, as discussed above, Defendant is entitled to little deference. Under these circumstances that court believes that it would be equitable and appropriate to consider Plaintiff's additional evidence. There is little or no evidentiary record, the court is concerned about the impartiality of the administrator, and Plaintiffs were unable to present this evidence during the administrative process because they were not given notice of what evidence was relied upon to make the decision. Nevertheless, the court will decide this case based solely on the information in the record.
In determining whether the Plan's decision is arbitrary and capricious, the court looks to factors such as whether there is a lack of substantial evidence, mistake of law, bad faith, or conflict of interest by the fiduciary. See Sandoval, 967 F.2d at 380 n. 4; Caldwell v. LINA, 287 F.3d 1276, 1282 (10th Cir. 2002). Even under the arbitrary and capricious standard, the decision regarding a claim can be upheld on review only if the Plan Administrator considered relevant factors in its analysis and offered a reasoned explanation for the denial of benefits based on the evidence and plan documents. Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999). Moreover, the Sandoval court recognized that a full and fair review requires: "knowing what evidence the decision-maker relied upon, having an opportunity to address the accuracy and reliability of the evidence, and having the decision-maker consider the evidence presented by both parties prior to reaching and rendering his decision." 967 F.3d at 382.
In this case, the May 11, 1999 letter sent from Kristen Campbell to Mr. Lemon indicated that there would be no coverage based on the Plan's exclusion for failure to wear a seat belt. The letter did not provide the evidence the decision-maker relied upon in making that determination. Therefore, the denial letter did not allow Plaintiffs an opportunity to address the accuracy and reliability of the evidence. Moreover, when Mr. Lemon submitted an appeal of the denial he provided Defendant with the name and telephone number of a witness to the accident. Defendant did not contact the witness. Therefore, Defendant failed to consider the evidence presented by both parties prior to reaching and rendering its decision. Accordingly, under the standards in Sandoval, Defendant did not conduct a full and fair review.
In Sandoval, the court noted that counsel for the plaintiff failed to present any additional evidence to the Administrator, after repeated invitations to do so. Furthermore, the plaintiff did not submit any additional relevant evidence to the committee for purposes of its review. In light of the plaintiff's choice not to participate fully in the review process, the denial of benefits was appropriate.
In contrast, in the present case, Mr. Lemon provided Defendant with the name and telephone number of a witness with relevant information. The letter Mr. Lemon sent to appeal the decision does not advance the argument that Corey was wearing his seatbelt. And, the affidavits from eyewitnesses and the EMT were also not before the administrator. However, Mr. Lemon's appeal did mention Debi Bentley and provided her telephone number. The Employee Benefits Committee did not follow up on this information.
Defendant argues that the Employee Benefits Committee had no duty to contact Debi Bentley because Mr. Lemon's letter did not dispute whether Corey was wearing a seatbelt and only advanced the argument that the policy exclusion for those not wearing seat belts was unfair. Defendants, however, ignore the fact that they are applying an exclusion to deny coverage under the Plan. The plaintiff carries the burden of showing a covered loss, but the defendant carries the burden of demonstrating facts that bring the loss under an exclusionary clause of the Plan. See Blair v. Metropolitan Life Ins. Co., 974 F.2d 1219, 1221 (10th Cir. 1992). "Under ERISA, an insurer bears the burden to prove facts supporting an exclusion of coverage. Federal courts treat insurer claims of policy exclusions as affirmative defenses." Fought, 357 F.3d at 1185 (10th Cir. 2004) (internal citations omitted). The provision invoked by Defendant to deny coverage in this case is within a section of the Plan clearly identified as "Exclusions." However, Defendant never provided Plaintiffs with any evidence to support its application of the exclusion.
It is also unclear from the Employee Benefits Committee's denial of the appeal what information it relied upon in making its determination. The July 9, 1999 letter from Paul Barnard, Defendant's Human Resource Director, stated only that the Employee Benefits Committee had considered the appeal and, although it was sympathetic to the situation, the Plan's guidelines regarding seat belt usage were specific and had to be adhered to for reimbursement. There was no indication in the letter what evidence Defendant had considered in making its determination. Not only did Defendant have an obligation to provide such information in order to conduct a full and fair review of the claim, it had the burden of demonstrating the evidence that allowed it to apply the exclusion to the claim.
Furthermore, Defendant's arguments are at odds with its fiduciary role under ERISA. The stated intent of ERISA is to protect plan participants from wrongfully losing their benefits. A plan administrator is charged with conducting a reasonable investigation before applying an exclusion. In this case, based on the language of the May 11, 1999 letter it is not even clear that Plaintiffs had made any claim under the Plan at the time the first denial was issued. However, after Mr. Lemon provided Debi Bentley's name in his appeal, the Employee Benefits Committee definitely had an obligation to notify Plaintiffs of whether it had contacted Debi Bentley for purposes of the appeal and, if not, why it did not contact her.
With respect to Defendant's failure to contact the witnesses named in Mr. Lemon's appeal, Defendant further claims that Debi Bentley was just one of the people "at the scene" identified in the letter who stated that a seat belt would not have helped Corey from being hurt worse. Plaintiffs counter that they never spoke to Debi Bentley. However, from the materials submitted in Mr. Lemon's appeal, there is no way of knowing to whom "the people at the scene" refers. It could refer to the EMT, the police, or any number of witnesses. Furthermore, the court concludes that it would be inappropriate to assess the letter in light of Defendant's failure to notify Plaintiffs of the evidence upon which it based its denial of the claim in the May 11, 1999 letter. Even if the court were to consider such arguments, Defendant chose not to talk to anyone who was at the scene. If Defendant had followed up with Debi Bentley it would have discovered that Corey was wearing his seatbelt when she arrived at the accident scene. Instead, it relied on only one report by the EMT. And, had Defendant actually spoken to the EMT who filled out the report it relied on, the court can only assume that he would have provided Defendant with the information he has provided this court — that he was not the first person on the scene and he could not say whether or not Corey was wearing a seatbelt at the time of the accident. Defendant would have then known that it needed to speak to others at the scene. This failure to consider or obtain any additional evidence, even when it was provided to Defendant on appeal, is additional evidence of the bias that occurred in the claims process. In any event, as stated above, the court need not assess or attempt to interpret the letter as Defendant requests because Defendant's failure to provide a full and fair review had already tainted the claims process by the time Mr. Lemon submitted his appeal.
In Gaither v. Aetna Life Insurance Company, 388 F.3d 759, 773 n. 5 (10th Cir. 2004), the Tenth Circuit recognized that when the failure to investigate leaves no adequate grounds for rejecting a claim, the overall decision was arbitrary and capricious. "While a fiduciary has a duty to protect the plan's assets against spurious claims, it also has a duty to see that those entitled to benefits receive them. It must consider the interests of deserving beneficiaries as it would its own." Id. at 774. "An ERISA fiduciary presented with a claim that a little more evidence may prove valid should seek to get to the truth of the matter." Id.
In this case, the plan administrator invoked an exclusion to deny benefits without reviewing the police report of the accident, without speaking to any witnesses at the scene of the accident, and without speaking to the EMT who prepared the report on which they relied. Had Defendant conducted a reasonable investigation it would have contacted Debi Bentley when her name was supplied on the appeal form, it would have learned that the police report conflicted with the EMT report, it would have learned that Debi Bentley told the police officer that Corey was wearing a seatbelt, and it would learned that the EMT could not say whether Corey was wearing a seatbelt because he was not the first person on the scene.
A full and fair review was not conducted in this case. Defendant's rush to denial demonstrates a serious conflict of interest and an unwillingness to "get to the truth." Moreover, Defendant's most significant error was its failure to identify to Plaintiffs the evidence upon which it relied to deny coverage. As a result, Plaintiffs were not given an adequate opportunity to rebut the evidence on appeal. Because Defendant's actions were arbitrary and capricious, this court reverses Defendant's denial of coverage under the Plan.
The parties stated at the oral argument on this matter that they did not agree as to the amount of medical bills at issue. The parties are given twenty days from the date of this order to reach a stipulation as to the appropriate amount. If the parties are unable to do so, they shall contact the court for a briefing schedule and hearing on the matter.
CONCLUSION
For the reasons stated above, Plaintiffs' Motion for Summary Judgment is GRANTED and Defendant's Motion for Summary Judgment is DENIED.