Linda Grabowski v. Hartford Life & Accident Ins.

• Court: Court of Appeals for the Fourth Circuit
• Decided: September 4, 2018
• Docket: 17-2108
• Status: Unpublished

Opinion

UNPUBLISHED

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

No. 17-2108

LINDA GRABOWSKI,

Plaintiff - Appellant,

v.

HARTFORD LIFE & ACCIDENT INSURANCE COMPANY,

Defendant - Appellee,

BAE SYSTEMS FUNDED WELFARE BENEFIT PLAN; BAE SYSTEMS ADMINISTRATIVE COMMITTEE; BAE SYSTEMS, INC.,

Defendants.

Appeal from the United States District Court for the Eastern District of Virginia, at Alexandria. Anthony John Trenga, District Judge. (1:16-cv-01384-AJT-JFA)

Submitted: July 31, 2018 Decided: September 4, 2018

Before WYNN, DIAZ, and HARRIS, Circuit Judges.

Affirmed by unpublished per curiam opinion.

Denise M. Clark, CLARK LAW GROUP, PLLC, Washington, D.C.; Carla N. McKain, McKAIN LAW, PLLC, Ithaca, New York, for Appellant. Elizabeth J. Bondurant, WOMBLE BOND DICKINSON, Atlanta, Georgia; Jerel C. Dawson, SHUTTS & BOWEN LLP, Miami, Florida, for Appellee.

Unpublished opinions are not binding precedent in this circuit.

2 PER CURIAM:

Linda Grabowski (Linda) appeals from the district court’s order denying her

motion for summary judgment and granting summary judgment to Defendant Hartford

Life and Accident Insurance Company (Hartford) in her civil action under the Employee

Retirement Income Security Act of 1974 (ERISA) challenging Hartford’s decision not to

pay accidental death and dismemberment (AD&D) benefits under an ERISA employee

benefit plan following the death of her husband Mark Grabowski (Mark). Finding no

reversible error, we affirm.

On April 15, 2013, Mark flew from Binghamton, New York, to Los Angeles,

California, as part of a business trip for his employer. Two days later, he collapsed and

died at his employer’s Los Angeles office. Prior to his death, Mark had participated in an

employee benefit plan (the plan) that provided basic and supplemental AD&D benefits

through policies administered by Hartford. Linda applied for benefits under both

policies, but Hartford denied her claims on the bases that Mark’s death did not result

from a traumatic accidental injury independent of all other causes and was caused or

contributed to by sickness or disease. Linda challenged this denial by filing the subject

action under the ERISA, and the parties filed cross-motions for summary judgment.

Applying an abuse of discretion standard, the district court affirmed the denial of benefits

and granted summary judgment to Hartford.

We review de novo the district court’s disposition of cross-motions for summary

judgment. Bostic v. Schaefer, 760 F.3d 352, 370 (4th Cir. 2014). “When cross-motions

for summary judgment are before a court, the court examines each motion separately,

3 employing the familiar standard under Rule 56 of the Federal Rules of Civil Procedure.”

Desmond v. PNGI Charles Town Gaming, L.L.C., 630 F.3d 351, 354 (4th Cir. 2011).

“Summary judgment is appropriate ‘if 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.’”

Lawson v. Union Cty. Clerk of Court, 828 F.3d 239, 247 (4th Cir. 2016) (quoting Fed. R.

Civ. P. 56(a)). A court should grant summary judgment unless a reasonable jury could

return a verdict for the nonmoving party on the evidence presented. Anderson v. Liberty

Lobby, Inc., 477 U.S. 242, 249 (1986).

Hartford had discretionary authority to determine eligibility for benefits under the

plan’s AD&D policies and to construe and interpret terms and provisions therein. Where

an ERISA plan grants an administrator discretion to award a benefit, we must review its

decision “only for abuse of discretion and . . . must not disturb the . . . decision if it is

reasonable, even if [we] would have reached a different conclusion.” Fortier v. Principal

Life Ins. Co., 666 F.3d 231, 235 (4th Cir. 2012) (internal quotation marks omitted).

A plan administrator’s decision “is reasonable if it is the result of a deliberate, principled

reasoning process and if it is supported by substantial evidence.” Evans v. Eaton Corp.

Long Term Disability Plan, 514 F.3d 315, 322 (4th Cir. 2008) (internal quotation marks

omitted).

Our reasonableness review applies to both a plan administrator’s factual findings

and interpretations of the plan. An administrator’s factual findings require substantial

evidence, that is, “more than a scintilla but less than a preponderance.” Newport News

Shipbuilding & Dry Dock Co. v. Cherry, 326 F.3d 449, 452 (4th Cir. 2003) (internal

4 quotation marks omitted). When reviewing the administrator’s findings for substantial

evidence, our review is limited to a review of “the evidence that was before the plan

administrator at the time of the decision.” Bernstein v. CapitalCare, Inc., 70 F.3d 783,

788 (4th Cir. 1995). When an administrator has interpreted a plan’s terms, we do not

construe ambiguities against the insurer who drafted the terms. See Carden v. Aetna Life

Ins. Co., 559 F.3d 256, 261 (4th Cir. 2009).

Judicial review for reasonableness also finds assistance in the non-exhaustive list

of factors this court set forth in Booth v. Wal-Mart Stores, Inc. Assocs. Health & Welfare

Plan, 201 F.3d 335 (4th Cir. 2000). The Booth factors include:

(1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary’s interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decisionmaking process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary’s motives and any conflict of interest it may have.

Id. at 342-43.

Linda argues on appeal that the district court erred for various reasons, but, after

review of the record and the parties’ briefs, we conclude that no reversible error is

present.

Linda faults the district court for allegedly failing to consider various Circuit and

district court decisions she contends support the proposition that death resulting from a

pulmonary embolism—the event listed in the medical examiner’s autopsy report and the

death certificate as the condition or event resulting in Mark’s death—and similar

5 conditions qualifies as accidental. But these cases are inapposite. In particular, her

reliance on Yasko v. Reliance Standard Life Insurance Co., 53 F. Supp. 3d 1059 (N.D. Ill.

2014) is misplaced. The facts there involved a death similar to Mark’s, which the district

court characterized as an “accident” under a similar policy. Id. at 1064. Critically,

however, the court there was applying de novo review to the interpretation of the policy’s

terms, rather than the abuse of discretion review we must apply here. Cf. Yasko on behalf

of Yasko v. Standard Ins. Co., No. 12 C 2661, 2014 WL 2155227, at *1 (N.D. Ill. May

19, 2014) (addressing same facts under different AD&D policy that gave the

administrator discretion to interpret terms of policy, and concluding that decision that the

death was not accidental was not unreasonable).

Linda also challenges as unreasonable Hartford’s interpretation of the terms

accident and accidental in the AD&D policies. She contends that, under Wickman v. Nw.

Nat’l Ins. Co., 908 F.2d 1077 (1st Cir. 1990), Mark’s death qualified as accidental.

She contends that Hartford’s denial of her claims on the grounds that there was no

evidence in Mark’s case of “traumatic” accidental injury was improper because that term

is not present in the AD&D policies. She further contends that Hartford’s denial decision

with respect to the basic AD&D policy essentially conceded that an accident occurred

and that holding otherwise is improper.

Under the abuse of discretion standard, however, Hartford only had to offer a

reasonable, and not the most reasonable, interpretation of plan terms. See McCorkle v.

Metro. Life Ins. Co., 757 F.3d 452, 459 (5th Cir. 2014) (explaining that abuse of

discretion standard prohibits a court from “substituting [its] own, narrower interpretation

6 of the term [“suicide”] in place of [the administrator’s] reasonable, yet broader,

interpretation” (internal quotation marks omitted)). The policies under the plan condition

AD&D benefits on the presence of an “accidental injury” and a “bodily injury

resulting . . . directly from an accident.” Hartford determined these circumstances were

not present because Mark died from the natural cause of a pulmonary embolism in the

absence of any trauma. We defer to Hartford’s interpretation that these circumstances do

not qualify as accidental. See King v. Penn. Life Ins. Co., 470 F. App’x 439, 444

(6th Cir. 2012) (No. 10-1672); Call v. Am. Int’l Grp., Inc., 621 F. Supp. 2d 352, 362

(S.D.W. Va. 2008). We further conclude that Wickman does not mandate a contrary

result. See Erbe v. Conn. Gen. Life Ins. Co., 695 F. Supp. 2d 232, 254-55 (W.D. Penn.

2010) (agreeing that Wickman “does not lend itself to cases such as the one at bar

involving deaths from heart attacks” and observing that cases applying Wickman were

concerned with “distinguishing between a death from an intentional act . . . or from

reckless behavior that the insured knew or should have known was likely to result in

death, and death that was accidental because it was merely the result of negligent

conduct” (internal quotation marks omitted)).

Linda also challenges as unreasonable Hartford’s reliance in denying benefits on

the autopsy report and death certificate. These documents provide information about the

biological factors contributing to Mark’s death, and Hartford did not act unreasonably in

relying on them in assessing whether Mark’s death was accidental. See Hancock v.

Metro. Life Ins. Co., 590 F.3d 1141, 1144 (10th Cir. 2009) (upholding administrator’s

determination of no entitlement to AD&D benefits because accidental death was not

7 established where medical examiner’s report concluded cause of death was

undetermined); Ruttenberg v. U.S. Life Ins. Co., 413 F.3d 652, 663 (7th Cir. 2005)

(ERISA plaintiffs must prove that their insurance contract entitles them to benefits).

Linda complains about Hartford’s claims review process, noting that it was

performed by a benefits specialist, without input from or analysis by a medical

professional. We reject this argument because Linda does not explain how this renders

Hartford’s process unreasonable. She further contends that her evidence submitted as

part of her administrative appeal was ignored and that Hartford failed to explain why it

did so. We reject this contention as flatly contradicted by the record.

Linda further argues that Hartford’s conflict of interest improperly influenced its

decisionmaking, as evidenced by its consultation with in-house counsel during her

administrative appeal. We conclude it was not unreasonable for Hartford to consult with

counsel during Linda’s administrative appeal, Olsen v. Standard Ins. Co., 40 F. Supp. 3d

1109, 1116 (D. Minn. 2014), and that this argument suggests no other basis for vacating

the district court’s judgment.

Finally, Linda argues that Hartford failed to meet its burden to prove the

applicability of a coverage exclusion for death caused or contributed to by a sickness or

disease. Because we conclude that Hartford did not act unreasonably in determining that

Mark’s death was not an accident or accidental under the policies, any lack of proof on

this point has no bearing on the outcome of this case.

8 Accordingly, we affirm the district court’s judgment. We dispense with oral

argument because the facts and legal contentions are adequately presented in the

materials before this court and argument would not aid the decisional process.

AFFIRMED