Clarke v. Federal Insurance

823 F. Supp. 2d 1213, 52 Employee Benefits Cas. (BNA) 2289, 2011 U.S. Dist. LEXIS 116206, 2011 WL 4757586
CourtDistrict Court, W.D. Oklahoma
DecidedOctober 7, 2011
DocketNo. CIV-10-1366-HE
StatusPublished
Cited by1 cases

This text of 823 F. Supp. 2d 1213 (Clarke v. Federal Insurance) is published on Counsel Stack Legal Research, covering District Court, W.D. Oklahoma primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Clarke v. Federal Insurance, 823 F. Supp. 2d 1213, 52 Employee Benefits Cas. (BNA) 2289, 2011 U.S. Dist. LEXIS 116206, 2011 WL 4757586 (W.D. Okla. 2011).

Opinion

ORDER

JOE HEATON, District Judge.

Anita M. Clarke filed this action1 seeking benefits under a Group Insurance Plan (“Plan”) established for certain employees of Anheuser-Busch Companies, Inc. and its subsidiaries. Plaintiffs decedent was a participant in the Plan, which is governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001-1461, and funded by a blanket accident policy issued by defendant Federal Insurance Company (“Federal”). After the death of her husband, plaintiff submitted an accidental death claim to Federal, which it denied. Both parties have filed motions requesting judgment on the Administrative Record.2

Background

On September 10, 2009, plaintiff returned to her home and discovered her husband’s body hanging from a braided ligature that was tied around his neck and around a banister in a bathroom. Ligatures also were tied around the decedent’s waist and genitals. At the time of his death the decedent was engaging in a sexual practice know as autoerotic asphyxiation.3 He had engaged in similar behavior twice before without incident, although his wife had told him not to do it when no one else was at their home because he could get hurt. There was no suicide note or message.4 No alcohol was found in the decedent’s system and plaintiff informed the sheriff that he had not taken drugs that day. Plaintiff told the sheriff that her husband had hung himself.5 The EMS report reflects that plaintiff stated her husband “had been known to do this kind of thing before” and had told the Grady County Sheriff that it was not intentional. AR 0475. The sheriff thought the decedent could have stood up at any time because of his height and the location of the ligature tied to the banister and around his neck. The Oklahoma Medical Examiner concluded the cause of death was hanging [1215]*1215and the manner of death was an accident. AR 0373.

Plaintiff submitted a claim for accidental death benefits under the Plan on November 16, 2009. During its claim investigation, Federal reviewed the EMS Report, the State Certificate of Death, the Sheriffs Report and the Medical Examiner’s Report and interviewed the investigating officer.6 Federal also considered prior legal memoranda regarding coverage under accidental death policies for autoerotic asphyxiation and then asked coverage counsel in December, 2009, to evaluate Tenth Circuit case law on the issue and consider the effect of the case being governed ERISA, rather than state law.7 Coverage counsel analyzed plaintiffs claim, determined it should be denied and drafted the letter sent to plaintiff dated February 25, 2010, that denied her claim.

In its denial letter, Defendant Federal concluded the death was not an accident resulting in a “loss” or was an intentionally self-inflicted loss that was excluded under the suicide or intentional injury exclusion. Federal stated:

The information provided to Federal indicates that Mr. Clarke specifically undertook to tie the ligature around his neck and the banister in the bathroom, and also intended to tie the additional ligatures around his waist and genital area, as part of engaging in auto-erotic asphyxiation. Federal does not consider these actions to constitute an “accident” as that term is used in the Policy and commonly understood. Moreover, even if the noted acts could be considered an “accident” — which Federal does not concede — Mr. Clarke’s death from engaging in an act that required hanging himself, was a type of Loss specifically excluded under the Suicide or Intentional Injury exclusion, i.e. one that was intentionally self-inflicted.

AR 0266. Plaintiff administratively appealed the denial and Federal’s ERISA Review Committee (“Committee”) again denied the claim, after reviewing the claim file, considering research done by coverage counsel and having “consulted with a number of industry experts on the practice of AEA.” AR 0006. In the denial letter, dated June 22, 2010, the Committee stated that it was

clear that Mr. Clarke voluntarily placed himself in a situation where he intentionally restricted the flow of blood/oxygen to his brain. While it is apparent that his motive in doing so was to derive heightened sexual pleasure, he nevertheless intentionally engaged in activity that involved injury or death as a foreseeable consequence. In fact, Anita Kay Clarke told the investigating sheriffs deputy that she had an earlier encounter where she found Mr. Clarke engaging in the same activity and she warned him not to do the activity alone because he could get hurt. Death is not accidental if it results from a foreseen risk purposefully brought about.

AR 0004. The Committee concluded the death was not an accident resulting in a “loss” and that coverage was precluded by the suicide or intentional injury exclusion.

Standard of review

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 [1216]*1216L.Ed.2d 80 (1989) sets forth the appropriate standard of review in cases contesting a benefit determination under an ERISA plan. “[A] denial of benefits challenged under § 1132(a)(1)(B) 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.”8 Id. at 115, 109 S.Ct. 948. If the ERISA plan “gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan, [the court] review[s] the administrator’s decision for an abuse of discretion.” Murphy v. Debate & Touche Group Ins. Plan, 619 F.3d 1151, 1157 (10th Cir.2010) (internal citations omitted). The court curtails its review “[u]nder the arbitrary and capricious standard, ... asking only whether the interpretation of the plan ‘was reasonable and made in good faith.’ ”9 Weber v. GE Group Life Assur. Co., 541 F.3d 1002, 1010 (10th Cir.2008) (quoting Flinders v. Workforce Stabilization Plan of Phillips Petroleum Co., 491 F.3d 1180, 1189 (10th Cir.2007)).

“Often the entity that administers [an ERISA] plan, such as an employer or an insurance company, both determines whether an employee is eligible for benefits and pays benefits out of its own pocket.” Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008). “[T]his dual role creates a conflict of interest.” Id.

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823 F. Supp. 2d 1213, 52 Employee Benefits Cas. (BNA) 2289, 2011 U.S. Dist. LEXIS 116206, 2011 WL 4757586, Counsel Stack Legal Research, https://law.counselstack.com/opinion/clarke-v-federal-insurance-okwd-2011.