Opinion
Civil Action No. 5:17-CV-214-C
08-31-2019
Brandy LONG, et al., Plaintiffs, v. AETNA LIFE INSURANCE COMPANY, Defendant.
Billy R. Wolfe, Wolfe & Associates, Lubbock, TX, Todd Michael Hurd, Todd Hurd & Associates, Burleson, TX, Christopher G. Lyster, Puls Haney PLLC, Fort Worth, TX, for Plaintiffs. Robert L. Craig, Jr., Brennon Duane Gamblin, Craig Terrill Hale & Grantham, Lubbock, TX, William Bernhart Wahlheim, Jr., Pro Hac Vice, Maynard Cooper & Gale, Birmingham, AL, for Defendant.
Billy R. Wolfe, Wolfe & Associates, Lubbock, TX, Todd Michael Hurd, Todd Hurd & Associates, Burleson, TX, Christopher G. Lyster, Puls Haney PLLC, Fort Worth, TX, for Plaintiffs.
Robert L. Craig, Jr., Brennon Duane Gamblin, Craig Terrill Hale & Grantham, Lubbock, TX, William Bernhart Wahlheim, Jr., Pro Hac Vice, Maynard Cooper & Gale, Birmingham, AL, for Defendant.
ORDER
SAM R. CUMMINGS, SENIOR UNITED STATES DISTRICT JUDGE
On this day, the Court considered:
(1) Defendant Aetna Life Insurance Company's Motion for Summary Judgment or, alternatively, for Judgment under Rule 52, filed May 24, 2019;
(2) Plaintiffs' Response to Defendant's Motion for Summary Judgment or, alternatively, for Judgment under Rule 52, filed June 21, 2019;
(3) Defendant Aetna Life Insurance Company's Reply Brief in Support of Defendant's Motion for Summary Judgment or, alternatively, for Judgment under Rule 52, filed July 12, 2019;
(4) Defendant Aetna Life Insurance Company's Objection to and Motion to Strike Dr. Parson's Affidavit, filed July 12, 2019;
(5) Plaintiffs' Response to Defendant's Objection to and Motion to Strike Dr. Parson's Affidavit, filed July 19, 2019; and
(6) Defendant Aetna Life Insurance Company's Reply Brief in Support of Its Objection to and Motion to Strike Dr. Parson's Affidavit, filed August 5, 2019.
Having considered the foregoing, the Court is of the opinion that Defendant's Motion for Summary Judgment or, alternatively, for Judgment under Rule 52 should be GRANTED in its entirety pursuant to Federal Rule of Civil Procedure 56.
I.
BACKGROUND
On August 21, 2017, Brandy Long, Nita D. Luca, Individually and as Executor of the Estate of Lisa Long, Deceased, and Dante Luca ("Plaintiffs") filed this civil action in the 242nd Judicial District Court of Hale County. Texas, against Aetna Life Insurance Company ("Defendant"). On September 14, 2017, Defendant removed this proceeding to the United States District Court for the Northern District of Texas, Lubbock Division, pursuant to 28 U.S.C. §§ 1331, 1441 and 1446.
To provide insight, Paul R. Long was employed by Republic Services, Inc. ("Republic") on September 9, 1996, and continued to work as a "roll over driver" until January 12, 2015. Defendant issued an insurance policy to Republic to insure the accidental death component of Republic's employee welfare benefit plan ("the Plan"). Mr. Long was employed by Republic at all relevant times and was a participant in the Plan. On April 30, 2015, Mr. Long ("decedent") died as a result of complications stemming from accidentally taking several prescription drugs at the same time and the drug intoxication that subsequently occurred. As a result, on September 24, 2015, Plaintiffs filed a claim for "basic life insurance benefits" in the amount of $47,675.00; "supplemental life benefits" in the amount of $100,000.00; "accidental death and supplemental accidental death benefits" in the amount of $47,675.00; and "supplemental accidental death and disability benefits" in the amount of $400,000.00. The following day, Defendant acknowledged that the basic life and supplement life benefits had been reviewed and were due and payable as a result of decedent's death. Defendant subsequently paid said benefits to Plaintiffs; however, Plaintiffs were advised that their claim for accidental death benefits were still under review.
The Policy at issue is Group Policy No. GP-815101 ("the Policy").
The Plan is an employer-sponsored plan under 29 U.S.C. § 1132 and governed by the Employee Retirement Income Security Act ("FRISA").
According to the medical examiner's autopsy report, Paul R. Long died of an accidental "acute combined drug intoxication." See Def.'s App. pp. 1279-82.
By letter dated August 17, 2018, Defendant advised Plaintiffs that their accidental death benefits claim was denied based upon a determination that decedent's death did not fall within the accidental death benefits coverage requirements as set forth within the Policy. See Def.'s App. pp. 1345-49. Defendant further upheld its determination on appeal by letter dated November 8, 2018. See id. at 1359-61. Accordingly, to date, Plaintiffs allege that Defendant has failed to pay their claim for "accidental death and supplemental accidental death benefits" in the amount of $47,675,00 and "supplemental accidental death and disability benefits" in the amount of $400,000.00. Plaintiffs contend that the Policy at issue does not contain any valid exclusion that would preclude payment of the amounts allegedly due.
Defendant now moves for summary judgment, therein arguing, inter alia , that the benefits at issue are not payable based upon its determination that: (1) the express definition of "accident" as used in the policy's coverage provisions requires that there be a "sudden external trauma" producing "objective symptom of a[n] external bodily injury" and that it, the "accident," not involve "a reaction to a drug or medication;" and (2) even if the coverage provisions somehow included the facts at issue, that hypothetical coverage would be excluded because the fatal medication was taken as prescribed by a physician and, therefore, the decedent's death was caused or contributed by "medical or surgical treatment."
II.
STANDARD
Summary judgment is appropriate when "the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a) ; Tagore v. United States , 735 F.3d 324, 328 (5th Cir. 2013). A material fact is one that might affect the outcome of the case under the governing law; a dispute concerning a material fact is genuine if the evidence is such that a reasonable jury could return a verdict for the non-moving party. Tagore , 735 F.3d at 328 (quoting Anderson v. Liberty Lobby, Inc. , 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986) ) (quotations omitted). To determine whether a genuine dispute exists such that the case must be submitted to a jury, courts must consider all of the evidence in the light most favorable to the non-moving party, draw all reasonable inferences in favor of the non-moving party, refuse to make credibility determinations or weigh the relative strength of the evidence, and disregard all evidence favorable to the movant that the jury would not be required to believe. Haverda v. Hays County , 723 F.3d 586, 591 (5th Cir. 2013).
If the burden at trial would be on the non-moving party, the movant must merely demonstrate "that there is an absence of evidence to support the non-moving party's case." Celotex Corp. v. Catrett , 477 U.S. 317, 325, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986) ; Bayle v. Allstate Ins. Co. , 615 F.3d 350, 355 (5th Cir. 2010). The burden then shifts to the non-moving party to produce evidence showing the existence of a genuine issue of material fact for trial. Bayle , 615 F.3d at 355 ; Fed. R. Civ. P. 56(e). To meet this burden, the non-movant must go beyond the pleadings and present specific facts indicating a genuine issue for trial. Bayle , 615 F.3d at 355. "[C]onclusory statements, speculation, and unsubstantiated assertions" are not specific facts and are not sufficient to defeat a motion for summary judgment. RSR Corp. v. Int'l Ins. Co. , 612 F.3d 851, 857 (5th Cir. 2010).
Whenever a plan administrator makes a benefit determination, the plan administrator does two things: (1) determines the facts underlying the benefit claim and (2) construes the terms of the plan. Wade v. Hewlett-Packard Dev. Co. LP Short Term Disability Plan , 493 F.3d 533, 537 (5th Cir. 2007). The general rule is that factual determinations are reviewed for abuse of discretion and plan interpretations are reviewed de novo. Id. at 537-38. However, when the plan gives the plan administrator discretion in interpreting the plan, then the administrator's interpretations are also reviewed for abuse of discretion. See Schexnayder v. Hartford Life and Acc. Ins. Co. , 600 F.3d 465, 469 (5th Cir. 2010) ; Wade , 493 F.3d at 538.
The Policy at issue provides that Defendant has "discretionary authority to determine whether and to what extent eligible employees and beneficiaries are entitled to benefits and to construe any disputed or doubtful terms under this Policy, the Certificate or any other document incorporated herein." Def.'s App. p. 72. Accordingly, the Court will review Defendant's decision for an abuse of discretion. Furthermore, although Texas prohibits discretionary clauses pursuant to the Texas Insurance Code, the Policy now before the Court was issued in Arizona to an employer in Arizona and "is governed by applicable federal law and the laws of Arizona." Id. at 57; see Rittinger v. Healthy All. Life Ins. Co. , 914 F.3d 952, 955 (5th Cir. 2019) (distinguishing Ariana M. v. Humana Health Plan of Tex., Inc. , 884 F.3d 246 (5th Cir. 2018), which held that de novo review applied because the plan could not validly delegate discretion under the Texas insurance code, as inapplicable where the policy was governed by Missouri law).
When a court reviews a plan administrator's interpretations for abuse of discretion, the court applies a two-step approach. Stone v. UNOCAL Termination Allowance Plan , 570 F.3d 252, 257 (5th Cir. 2009). First, the court determines if the administrator's determination was legally correct. In making this determination, the court considers "(1) whether the administrator has given the plan a uniform construction, (2) whether the interpretation is consistent with a fair reading of the plan, and (3) any unanticipated costs resulting from different interpretations." Id. at 258 (quoting Crowell v. Shell Oil Co. , 541 F.3d 295, 312 (5th Cir. 2008) ). "Whether the administrator's interpretation is consistent with a fair reading of the plan is the most important factor to consider in the three-step analysis." Crowell , 541 F.3d at 312-13 (internal quotations, citations and alternations omitted). Second, if the interpretation is legally correct, the inquiry ends and there is no abuse. Stone , 570 F.3d at 257. However, if the court finds that the interpretation was legally incorrect, the court must then determine whether the decision was an abuse of discretion. Id. "Only upon reaching this second step must the court weigh as a factor whether the administrator operated under a conflict of interest." Id. This Circuit does not consider a conflict of interest until the second stage of the analysis. Id. at 258.
"If the plan fiduciary's decision is supported by substantial evidence and is not arbitrary and capricious, it must prevail." Schexnayder , 600 F.3d at 468. "Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Lain v. UNUM Life Ins. Co. of Am. , 279 F.3d 337, 342 (5th Cir. 2002). A court's "review of the administrator's decision need not be particularly complex or technical; it need only assure that an administrator's decision fall somewhere on a continuum of reasonableness–even if on the low end." Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389 (5th Cir. 2007).
III.
DISCUSSION
Preliminary Matters—Defendant's Motion to Strike
As a threshold matter. Defendant objects to and moves to strike Plaintiffs' submission of Dr. Thomas R. Parsons' affidavit in support of Plaintiffs' Response to Defendant's Motion for Summary Judgment or, alternatively, for Judgment under Rule 52. Specifically, Defendant argues that the affidavit and the exhibits thereto are neither part of the Administrative Record, nor within the limited exceptions that may be considered in an ERISA benefits case pursuant to Fifth Circuit precedent. As a result, Defendant avers that the affidavit and the exhibits should be stricken and disregarded for purposes of summary judgment. Conversely, Plaintiffs contend that Dr. Parson's affidavit and the exhibits at issue are relevant to cure alleged deficiencies within the administrative record. Essentially, Plaintiffs argue that the information contained within the affidavit provided by Dr. Parsons should not be new to Defendant had Defendant conducted an adequate and thorough investigation of Plaintiffs' claim.
Fifth Circuit precedent acknowledges that the Court's holding in Vega v. National Life Insurance Services, Inc. "prohibits the admission of evidence to resolve the merits of the coverage determination—i.e. whether coverage should have been afforded under the plan—unless the evidence is in the administrative record, relates to how the administrator has interpreted the plan in the past, or would assist the court in understanding medical terms and procedures." Crosby v. Louisiana Health Serv. & Indem. Co. , 647 F.3d 258, 263 (5th Cir. 2011). Moreover, "[a] plan participant is not entitled to a second chance to produce evidence demonstrating that coverage should be afforded." Id. However, "Vega does not ... prohibit the admission of evidence to resolve other questions that may be raised in an ERISA action. For example, ... a claimant may question the completeness of the administrative record; whether the plan administrator complied with ERISA's procedural regulations; and the existence and extent of a conflict of interest created by a plan administrator's dual role in making benefits determinations and funding the plan." Id.
188 F.3d 287 (5th Cir. 1999) (en banc), abrogated on other grounds by Metro. Life Ins. Co. v. Glenn , 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008), as recognized in Holland v. Int'l Paper Co. Ret. Plan , 576 F.3d 240, 247 n. 3 (5th Cir. 2009).
"The administrative record consists of relevant information made available to the administrator prior to the complainant's filing of a lawsuit and in a manner that gives the administrator a fair opportunity to consider it." Estate of Bratton v. Nat'l Union Fire Ins. Co. of Pittsburgh , 215 F.3d 516, 521 (5th Cir. 2000) (citations omitted).
See Estate of Bratton v. National Union Fire Insurance Company, 2 15 F.3d 516, 521 (5th Cir. 2000) (indicating that a claimant may contest whether the identified administrative record is complete).
Having considered the parties' contentions and all relevant records, the Court is of the opinion that Defendant's Motion to Strike should be GRANTED and that Defendant's objections be SUSTAINED . The Court finds that the admission of the evidence at issue would stray from the mandates imposed pursuant to Fifth Circuit precedent. Accordingly, the Court ORDERS that Dr. Thomas R. Parsons' affidavit and the exhibits thereto, as contained in Plaintiffs' Appendix in Support of Plaintiffs' Response to Defendant's Motion for Summary Judgment, be STRICKEN from the record for purposes of summary judgment.
To the extent Plaintiffs' Response to Defendant's Objection to and Motion to Strike Dr. Parson's Affidavit could plausibly be construed as a motion for continuance pursuant to Federal Rule of Civil Procedure 56(d), the Court is of the opinion that the same should be DENIED for the reasons stated in Defendant's Reply Brief. See Doc. 42.
Specifically, the Court STRIKES Plaintiffs' App. pp. 1-2 & 13-19.
Employee Retirement Income Security Act—Generally
The Fifth Circuit has held that the rights and obligations stemming from ERISA-regulated insurance plans are governed by federal common law (rather than state law), including the interpretation of policy provisions. Green v. Life Ins. Co. of N. Am. , 754 F.3d 324, 331 (5th Cir. 2014). Accordingly, courts must give the language of an insurance contract its "ordinary and generally accepted meaning" where such a meaning exists. Id. Courts are to apply the rule of contra proferentum and construe terms strictly in favor of the insured only "if the plan terms remain ambiguous after applying ordinary principles of contract interpretation." Id.
Accident
As to the specific claim at issue, the policy provides that "[a] benefit is payable for certain losses if both of the following occur while your coverage is in effect: [1] you are involved in an accident; and [2] you suffer a bodily injury as a direct result of the accident." Accident is defined as:
Def.'s App. p. 84.
[A] sudden external trauma that is; unexpected; and unforeseen; and is an identifiable occurrence or event producing, at the time, objective symptoms of an external bodily injury. The accident must occur while the person is covered under this Policy. The occurrence or event must be definite as to time and place. It must not be due to, or contributed by, an illness or disease of any kind including a reaction to a condition that manifests within the human body or a reaction to a drug or medication regardless of the reason you have consumed the drug or medication.
Id. at 32.
Based upon the aforementioned definition, Defendant first argues that the benefits at issue are not payable due to the fact that decedent's death was not the direct result of an injury caused by an "accident." Specifically, Defendant contends that the administrative record conclusively establishes that, as to the definition of accident, there was not a "sudden external trauma" causing "external bodily injury." Defendant further argues that decedent's death was undisputedly the result of a fatal reaction between medications and that the definition of "accident" expressly precludes an "illness or disease" such as a "reaction to a drug or medication."
i. Definitional requirement of "External Bodily Injury"
In order for the benefits to be payable, the policy first requires that there be an accident, meaning a sudden external trauma that is unexpected, unforeseen, and is an identifiable occurrence or event producing, at the time, objective symptoms of an external bodily injury. Defendant avers that there was no "sudden external trauma" that caused a bodily injury that was the sole and direct cause of decedent's death. In support, Defendant points to the administrative record, specifically decedent's autopsy report, which clearly states that "[t]here is no acute evidence of trauma on the surface of the body." Based on the foregoing and having conducted a thorough review of the administrative record, the Court is guided to conclude that there was no "sudden external trauma" causing bodily injury and resulting in decedent's death.
Id. at 1312.
ii. "Illness or Disease" due to a "Reaction to Drug or Medication"
The policy further provides that an "accident" must not be due to, or contributed by, an illness or disease of any kind including a reaction to a condition that manifests within the human body or a reaction to a drug or medication regardless of the reason you have consumed the drug or medication. The administrative record conclusively establishes that decedent's death was the result of an acute combined drug intoxication. Accordingly, the Court finds that there is no coverage due to the policy's language placing an "illness or disease of any kind, ... a reaction to a drug or medication" beyond the scope of the term "accident" "regardless of the reason [decedent] consumed the drug or medication."
As to the exclusionary provision concerning the "use of drugs, except as prescribed by a physician," the language of an exclusion cannot serve to create coverage when coverage does not already exist. See Century Sur. Co. v. Seidel , 893 F.3d 328, 335 (5th Cir. 2018), cert. denied , ––– U.S. ––––, 139 S. Ct. 1326, 203 L.Ed.2d 566 (2019) ("[T]he language of an exclusion simply does not create coverage.").
Medical Treatment Exclusion
Assuming, arguendo , that decedent's death could plausibly be categorized as an "accident." the Court finds that coverage would be excluded under the medical treatment exclusion. According to the policy's exclusions, "no benefits are payable for a loss caused or contributed to by ... Medical or surgical treatment" except where the loss is caused by "[a]n infection which results directly from an accident [or] [s]urgery needed because of an injury." As applicable here, decedent's death was undisputedly contributed to by medical treatment. furthermore, the administrative record supports the finding that decedent's death was neither caused by an infection resulting from an "accident," nor surgery needed due to an injury. Accordingly, and in the alternative, the Court finds the policy's medical treatment exclusion applicable to serve as an additional basis for the denial of benefits under the policy.
Def.'s App. pp. 102-03.
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IV.
CONCLUSION
For the reasons set forth herein and having determined that Defendant's denial of the benefits at issue was not an abuse of discretion, the Court hereby ORDERS that Defendant's Motion for Summary Judgment be GRANTED and that Plaintiffs' claims be DISMISSED .
SO ORDERED this 31st day of August, 2019.