Clark v. Life Insurance Co. of North America

950 F. Supp. 2d 1348, 2013 WL 3005289, 2013 U.S. Dist. LEXIS 85541
CourtDistrict Court, N.D. Georgia
DecidedJune 18, 2013
DocketCivil Action File No. 1:12-cv-1977-TCB
StatusPublished
Cited by1 cases

This text of 950 F. Supp. 2d 1348 (Clark v. Life Insurance Co. of North America) is published on Counsel Stack Legal Research, covering District Court, N.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Clark v. Life Insurance Co. of North America, 950 F. Supp. 2d 1348, 2013 WL 3005289, 2013 U.S. Dist. LEXIS 85541 (N.D. Ga. 2013).

Opinion

ORDER

TIMOTHY C. BATTEN, SR., District Judge.

This case comes before the Court on the parties’ cross-motions for judgment on the administrative record [15,16].

I. Background

In this action, Plaintiff Marge Clark seeks to recover insurance benefits under an insurance policy issued to Citigroup N.A. by Defendant Life Insurance Company of North America (“LINA”). The policy provides for accidental death and dismemberment benefits under an employee welfare benefit plan sponsored and maintained by Citigroup and governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001. Clark is a beneficiary of the accidental-death policy, as her husband Jeffrey Clark was an employee of Citigroup and a plan participant. Clark seeks benefits as a result of Jeffrey’s untimely death.

On June 7, 2009, around 3 p.m., Jeffrey was riding his motorcycle eastbound on Colorado Highway 72 in Boulder, Colorado, when he skidded off the road, was thrown from the motorcycle, and collided with a tree. Tragically, Jeffrey died as a result of the injuries he sustained.

The subsequent investigation showed that at the time of the accident Jeffrey was not wearing a helmet;1 he had a 0.176 [1350]*1350gm/dL blood alcohol concentration (“BAC”); and he tested positive for marijuana.

The investigation also showed that Jeffrey was riding downhill below the speed limit. He was approaching a curve on a dry, paved road when he appears to have braked hard and skidded twenty-six feet to the right, off the road. There were no adverse weather conditions at the time of the crash, and there were no other vehicles involved in the crash. There also were no defects or obstacles in the road.

Clark told LINA that Jeffrey was an experienced motorcycle rider who knew how to handle his motorcycle and was well familiar with the road on which the crash occurred. She also stated that visibility on the curve is limited, which makes it harder for motorists to see oncoming traffic until “entering the curve.” She contends that the point where Jeffrey could see oncoming traffic is where the skid marks began.

On July 19, 2009, Clark filed a claim for accidental-death benefits, which LINA received on September 1. At the time of his unexpected death, Jeffrey’s death benefits under the policy were $107,000. In her claim, Clark stated that “something or someone forced Jeffrey D. Clark off the road at mile marker 43 and he was thrown from his motorcycle and fell 20 feet [and] died.”

The policy provides that LINA will “pay benefits for loss from bodily injuries: a) caused by an accident which happens while an insured is covered by this policy; and b) which, directly and from no other causes, result in a covered loss.” The policy does not define “accident.”

The parties agree that LINA has discretion to determine claims under the policy and to interpret the policy’s provisions. Also, LINA does not have numerical guidelines or quotas regarding claim payments or denials. Employees who initially evaluate claims are paid fixed salaries that are unrelated to the amount or number of claims they approve or deny. In addition, these employees do not receive any incentive or reward and are not evaluated based on the number of claims they approve or deny. Also, LINA’s appeal unit is completely separate from the initial evaluation unit. The employee reviewing an appeal does not discuss the claim with the employee who made the initial determination. Furthermore, the financial underwriters are separate from the claims department and appeal unit, neither of which is required to seek approval from the underwriters before máking a decision.

By letter dated October 9, 2009, LINA informed Clark that it was denying her claim. The letter said that under the policy an accident was a “sudden, unforeseeable, external event” and that a loss that results from “an action whose outcome is reasonably foreseeable is not a Covered Accident as this policy defines it.” LINA explained that “[s]erious injury and death ... are foreseeable outcomes of operating a motor vehicle while legally intoxicated.” Thus, LINA determined that a loss “resulting from driving while under the influence of alcohol is not an unforeseeable Covered Accident,” and it denied Clark’s claim. LINA’s letter stated that if Clark could prove that Jeffrey’s death “did not result from driving under the influence of alcohol or THC [marijuana]” it would reconsider her claim.

By letter dated December 4, 2009, Clark appealed LINA’s initial decision. She contended that the denial was based on insufficient facts and incorrect analysis. She [1351]*1351reiterated that Jeffrey’s death was “the result of an unforeseen and unexpected circumstance in the roadway, which he attempted to avoid, but which caused him to lose control of the motorcycle and crash. His death was an accident, which is not altered by the findings of the toxicological studies.” As discussed below, Clark did not provide any evidence to support her assertion that something or someone in the road caused Jeffrey to lose control and die in the subsequent crash.

By letter dated December 23, 2009, LINA affirmed its initial decision and denied Clark’s appeal.

On June 7, 2012, Clark filed this action. On February 22, 2013, the parties filed cross-motions for judgment on the administrative record.

II. Legal Standard

Although ERISA does not provide a standard for courts reviewing an administrator’s denial of benefits, the Eleventh Circuit has provided a “multi-step framework to guide courts in reviewing an ERISA plan administrator’s benefits decisions.” Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1354 (11th Cir.2011). The steps are:

(1) Apply the de novo standard to determine whether the claim administrator’s benefits-denial decision is “wrong” (i.e., the court disagrees with the administrator’s decision); if it is not, then end the inquiry and affirm the decision.
(2) If the administrator’s decision in fact is “de novo wrong,” then determine whether he was vested with discretion in reviewing claims; if not, end judicial inquiry and reverse the decision.
(3) If the administrator’s decision is “de novo wrong” and he was vested with discretion in reviewing claims, then determine whether “reasonable” grounds supported it (hence, review his decision under the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse the administrator’s decision; if reasonable grounds do exist, then determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the court to take into account when determining whether an administrator’s decision was arbitrary and capricious.

Id. at 1355 (citing Capone v. Aetna Life Ins. Co.,

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950 F. Supp. 2d 1348, 2013 WL 3005289, 2013 U.S. Dist. LEXIS 85541, Counsel Stack Legal Research, https://law.counselstack.com/opinion/clark-v-life-insurance-co-of-north-america-gand-2013.