Kurt Johnson v. Connecticut General Life Insurance

324 F. App'x 459
CourtCourt of Appeals for the Sixth Circuit
DecidedApril 7, 2009
Docket08-3347
StatusUnpublished
Cited by38 cases

This text of 324 F. App'x 459 (Kurt Johnson v. Connecticut General Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kurt Johnson v. Connecticut General Life Insurance, 324 F. App'x 459 (6th Cir. 2009).

Opinions

RALPH B. GUY, JR., Circuit Judge.

Defendant Connecticut General Life Insurance Company (Connecticut General) appeals from the district court’s decision to enter judgment on the administrative record in favor of plaintiff Kurt Johnson, as beneficiary, on his claim for benefits under [461]*461an ERISA-governed group supplemental life insurance policy obtained by his wife, Kristen Johnson, less than two years before her death.1 Connecticut General asserts that the district court erred by: (1) considering and allowing discovery regarding Connecticut General’s alleged conflict of interest; (2) finding that the Ohio statute addressing false statements in applications for life insurance was not preempted by ERISA; and (3) concluding that Connecticut General’s denial of the claim was arbitrary and capricious. After review of the record and the applicable law, we affirm.

I.

On November 15, 2003, during an open enrollment period, Kristen Johnson applied for additional life insurance under a policy she already had through her employer. She completed a supplemental enrollment form at the time of application, and submitted to a paramedical exam and interview on December 26, 2003. Connecticut General approved the additional coverage on January 8, 2004, without conducting a review of her medical records. The policy provided that any increase in coverage would be incontestable after the increase has been in force for two years.

On October 4, 2005, 20 months after the increase was approved, Kristen Johnson was sent to the emergency room, went into a coma, and died the next day. The death certificate identified cardiac arrest and pulmonary embolism as causes of death, and noted that hypertension was a contributing condition. Kurt Johnson, Kristen’s husband, made a claim for benefits in November 2005. Connecticut General paid the $88,000 benefit due under the original insurance policy, but took the claim for the $174,000 in additional insurance benefits under review. Claim Specialist Linda Ca-navan requested three years of medical records from Drs. Coleflesh and Balias, and then asked plaintiff to identify any other doctors his wife had seen.2 Plaintiff called and provided the names of Drs. Morisetty and Parepally. With records from Drs. Coleflesh, Morisetty, and Pare-pally, the claim was sent to medical underwriting for review in January 2006.

In a March 20, 2006 letter, Connecticut General informed plaintiff of its decision to rescind the additional coverage on the grounds that the insured had made material misrepresentations in the supplemental enrollment form. Specifically, Connecticut General explained that although Kristen Johnson had disclosed a history of hypothyroidism diagnosed in April 2002,

[t]he medical records from Riverside Medical of Ohio indicated that she was diagnosed with hypertension in 2002; palpitations; asthma and shortness of breath documented in records from July 2, 2002 and January 16, 2003 and poly-cystic ovarian disease. Kristen Robinson-Johnson had the opportunity and obligation to disclose her full medical history at the time of application, in response to Questions B, C, E and G and a second opportunity in response to Questions 5, 9 and 10 at the time of her paramedical exam.

Connecticut General concluded that if it had been aware of her medical history, the [462]*462additional coverage would not have been approved. In May 2006, plaintiff, through counsel, appealed from the denial and disputed that the medical records referenced by Connecticut General reflected prior diagnoses of hypertension, palpitations, or cystic ovarian disease. The shortness of breath, plaintiff argues, was determined not to. be asthma but rather ventilatory muscle weakness due to the hypothyroidism.

Connecticut General denied plaintiffs appeal on June 26, 2006, reiterating the conditions that had not been disclosed and stating more precisely that Kristen Johnson had “advised her physician that she was hospitalized in 2002 for hypertension.” This time, Connecticut General specified that coverage would have been denied if the insured had disclosed “her full medical history of hypothyroidism, hypertension and palpitations.” Connecticut General would later concede that the insured had no history of palpitations or polycystic ovarian disease prior to the application for additional insurance. In addition, Connecticut General clarified that it was actually the combination of “hypothyroidism” and “hypertension” that would have resulted in an automatic denial of coverage.

This action, filed in January 2007, asserted state law claims for declaratory judgment and breach of contract. On Connecticut General’s motion to dismiss, the district court agreed that the state law claims were preempted by ERISA’s enforcement provisions; found that plaintiff should be permitted to amend to assert an ERISA claim for benefits; and concluded that an Ohio statute nonetheless provided the applicable “rule of decision” for plaintiffs ERISA benefit claim. After discovery concerning Connecticut General’s apparent conflict of interest and briefing on the merits, the district court concluded that Connecticut General’s decision to rescind coverage was arbitrary and capricious. The district court granted plaintiffs motion for judgment on the administrative record, and this appeal followed.

II.

Both the district court and this court review a decision denying ERISA benefits de novo, unless — as is the case here — the plan gives the administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Kalish v. Liberty Mut./Liberty Life Assur. Co., 419 F.3d 501, 506 (6th Cir.2005). When the administrator is given such discretion, the denial of benefits is reviewed under the arbitrary and capricious standard. Id. (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). Where there is an inherent conflict of interest, the standard is not altered but the conflict must be weighed as a factor in determining whether the decision was arbitrary and capricious. Id.; see also Metro. Life Ins. Co. v. Glenn, -U.S.-, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008).

A. Application of Ohio Rev.Code § 3911.06

Connecticut General argues that the district court erred in applying this state law as the “rule of decision” in its review of the ERISA claim for benefits. There is no dispute that Ohio Rev.Code § 3911.06 “relates to” an employee benefit plan and would be preempted by § 514(a) of ERISA unless exempted from preemption by § 514(b)(2)(A) of ERISA, which “saves” from preemption the “law of any State which regulates insurance, banking, or securities.” 29 U.S.C. § 1144(a) and (b)(2)(A). Whether ERISA preempts a particular state statute is a question of law that we review de novo. Crabbs v. Copper-[463]*463weld, Tubing Prods. Co., 114 F.3d 85, 89 (6th Cir.1997).

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324 F. App'x 459, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kurt-johnson-v-connecticut-general-life-insurance-ca6-2009.