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Denial of Accidental Death Claim Based On Alcohol Exclusion Was <em>De Novo</em> Correct

Denial of Accidental Death Claim Based On Alcohol Exclusion Was De Novo Correct


ERISA and Life Insurance News
(May 11, 2012)

Smith was covered by an ERISA-governed accidental death insurance policy provided by his employer. Smith died in a one-car collision, and a toxicology report showed that his blood ethyl alcohol content was 0.206 grams per 100 ml at the time of death.

Smith’s wife, as his beneficiary, claimed accidental death benefits. Hartford denied the claim, based on an exclusion for "loss caused or contributed to by the injured person’s intoxication." Intoxication was defined to mean "that blood alcohol content or the results of other means of testing blood alcohol level, meet or exceed the legal presumption of intoxication under the law of the state where the accident took place."

Mrs. Smith sued, and the federal district court relied on the six-step analysis applied by the Eleventh Circuit to review ERISA benefits decisions: (1) determine whether the benefits-denial decision is de novo wrong; (2) if the decision was wrong, determine whether the administrator had discretion; if not, reverse the decision; (3) if there was discretion, determine whether the decision was reasonable; (4) if the benefits decision was not reasonable, reverse it; if it was reasonable, then determine if there was a conflict of interest; (5) if there is no conflict, affirm the decision; (6) if there was a conflict, consider it as merely one factor in determining whether the benefits-denial was arbitrary and capricious.

Citing Buce v. Allianz Life Insurance Company, 247 F.3d 1133 (11th Cir. 2001), the court declared that, because the federal common law of ERISA supersedes state law, Georgia’s "accidental means" doctrine was inapplicable. Rather, the court considered the standard established by Wickman v. Northwestern National Insurance Company, 908 F.2d 1077 (1st Cir. 1990), that the court must consider whether the insured "knew or should have known that serious bodily injury or death was a probable consequence substantially likely to occur as a result of his volitional act …."

Based on Wickman and its progeny, the court determined that Hartford’s denial was not de novo wrong, the first step in the analysis. Although there was insufficient evidence to determine Smith’s state of mind on the night of the collision, the court held that, objectively, death was the foreseeable result of driving while intoxicated to an extent greater than twice the legal limit.

In making this determination, the court rejected studies proffered by Mrs. Smith showing that death from drunk driving is not "substantially probable." Because those studies had not been submitted to Hartford, they were not part of the administrative record considered by the court in its reasonableness determination. Furthermore, such statistics have been refuted under similar circumstances as failing to take into account the degree of intoxication of the driver and the fact that the risk of being involved in a fatal crash increases as blood alcohol levels rise.

Mrs. Smith also argued that Hartford denied the claim simply because of Smith’s blood alcohol content, without conducting an investigation to determine whether intoxication actually caused the crash. While agreeing that the law disfavors per se rules in intoxication cases, the court disagreed that Hartford had made a per se decision, citing the myriad documents reviewed by Hartford regarding the incident, coupled with the fact that nothing else in the record pointed to any other factor which might have contributed to the crash.

The court went on to say that, even if Hartford’s decision were de novo wrong, Hartford was granted discretion under the plan, and its determination was reasonable. The court found nothing in the record to indicate that Hartford was influenced by its conflict of interest. Thus, the court granted Hartford’s motion for summary judgment.

Click Here to view the full May 2012 Edition of the ERISA and Life Insurance News. 

Authors
H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Associated Attorneys
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