Reiling ex rel. B.J.W.R. v. Sun Life Assurance Co. of Canada

66 F. Supp. 3d 1361, 2014 U.S. Dist. LEXIS 168639, 2014 WL 6895951
CourtDistrict Court, D. Kansas
DecidedDecember 5, 2014
DocketCase No. 6:13-CV-01349-JAR
StatusPublished

This text of 66 F. Supp. 3d 1361 (Reiling ex rel. B.J.W.R. v. Sun Life Assurance Co. of Canada) is published on Counsel Stack Legal Research, covering District Court, D. Kansas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Reiling ex rel. B.J.W.R. v. Sun Life Assurance Co. of Canada, 66 F. Supp. 3d 1361, 2014 U.S. Dist. LEXIS 168639, 2014 WL 6895951 (D. Kan. 2014).

Opinion

MEMORANDUM AND ORDER

JULIE A. ROBINSON, District Judge.

Plaintiff Brenda Reiling brings this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), seeking judicial review of Defendant Sun Life Assurance Company’s denial of her claim for accidental death benefits. This matter is before the Court on the parties’ cross-motions for summary judgment (Docs. 35 and 37). For the reasons stated in detail below, the Court grants Plaintiffs motion for summary judgment and denies Defendant’s motion for summary judgment.

I. Background

The late Jennifer Reiling (“Ms. Reiling”) was a participant in an employee benefit plan sponsored by her employer, Sonic Restaurants, Inc. (“Sonic”). The plan, which is subject to the provisions of ERISA, provides employees with life and accidental death benefits through a group insurance policy (the “Policy”) issued by Defendant. The Policy requires Defendant to pay accidental death benefits upon proof that an insured employee died from an accidental bodily injury. The Policy excludes coverage, however, “for a loss which is due to or results from: ... committing or attempting to commit an assault; felony or other criminal act.”1 Sonic has delegated to Defendant its entire discretionary authority to construe the Policy’s terms and to determine eligibility for benefits claimed under the Policy.

Ms. Reiling died in a car accident on July 1, 2012. The Kansas Motor Vehicle Accident Report states that Ms. Reiling was driving east on U.S. Highway 54 when a westbound vehicle crossed the center line and collided with Ms. Reiling’s car. The driver of the westbound vehicle survived, but Ms. Reiling passed away at the crash site. The investigating officer determined that, at the time of the accident, Ms. [1365]*1365Reiling was driving with a suspended license — a class B misdemeanor under Kansas law.2

Plaintiff, Ms. Reiling’s mother, submitted a claim for accidental death benefits on behalf of Ms. Reiling’s two minor children. Ms. Reiling had elected to pay for accidental death coverage totaling $75,000 and seat belt and air bag coverage totaling $26,250. In a letter dated November 16, 2012, Defendant notified Plaintiff that those benefits were not payable: because Ms. Reiling was driving with a suspended license at the time of the accident, Defendant determined that “the injuries resulting in Jennifer’s death falls [sic] within the Policy exclusion applicable to ‘committing or attempting to commit an assault, felony or other criminal act.’ ”3

Plaintiff appealed. On March 14, 2013, Defendant issued a written decision upholding its denial of accidental death benefits. Defendant had confirmed with the officer in charge of investigating Ms. Reil-ing’s accident that driving with a suspended license was a criminal act under Kansas law, and Defendant therefore affirmed its finding that Ms. Reiling’s loss was “due to or resulted] from” her criminal act. Defendant informed Plaintiff that she had exhausted all administrative remedies available under the Policy. Plaintiff now seeks review in this Court, claiming Defendant’s denial of accidental death benefits was arbitrary and capricious.

II. Summary Judgment Standard

Summary judgment is appropriate if the moving party demonstrates that there is no genuine dispute as to any material fact and that it is entitled to judgment as a matter of law.4 “Where, as here, the parties file cross-motions for summary judgment, [the Court is] entitled to assume that no evidence needs to be considered other than that filed by the parties, but summary judgment is nevertheless inappropriate if disputes remain as to material facts.”5 The Court considers cross-motions separately: the denial of one does not require the grant of the other.6 “To the extent the cross-motions overlap, however, the Court may address the legal arguments together.”7 The material facts are undisputed in this case, and the legal issues asserted with respect to both motions are identical. The Court will therefore address those'issues tpgether.

III. Discussion

Plaintiff contends that Defendant’s interpretation of the Policy’s criminal-act exclusion was arbitrary and capricious for two reasons: (1) an ordinary plan participant would view driving while suspended as a traffic violation, not a criminal act; and (2) the causal link between Ms. Reil-ing’s death and her driving while suspended is too attenuated to satisfy the causal nexus required under the terms of the .criminal-act exclusion. The Court will address each contention in turn. But first [1366]*1366the Court must determine the appropriate standard for reviewing Defendant’s decision to deny benefits.8

A. Standard of Review

In interpreting ERISA plans, courts must give plan language “its common and ordinary meaning as a reasonable person in the position of a [plan] participant ... would have understood the words to mean.”9 ERISA plan administrators may retain discretionary authority to construe the terms of the plan.10 Where, as here, the plan administrator has retained this authority “in explicit terms, [courts] employ a deferential standard of review, asking only whether the denial of benefits was arbitrary and capricious.”11 Under the arbitrary and capricious standard, the Court must uphold Defendant’s determination so long as it is reasonable.12 “Indicia of arbitrary and capricious decisions include lack of substantial evidence, mistake of law, bad faith, and conflict of interest by the fiduciary.”13

The parties do not dispute that the Policy, gives Defendant discretionary authority to determine eligibility for benefits and to construe the terms of the Policy. Nor do they dispute that Defendant, which functions as both administrator and insurer, operates under a conflict of interest because it is in a position to favor its own financial interests over the interests of Ms. Reiling’s beneficiaries.14 The Court will therefore weigh the conflict of interest as a factor in determining whether Defendant’s decision was arbitrary and capricious.15 Though the Court does not “dial back [its] deference,” 16 a conflict “should prove more important (perhaps of great importance) where circumstances suggest a higher likelihood that it affected the benefits decision ... [and] should prove less important (perhaps to the vanishing point) where the administrator has taken active steps to reduce potential bias and to promote accuracy.” 17

Here, there is no indication that Defendant has taken steps to reduce potential bias. The record shows that Defendant’s claims analysts made the decision to deny benefits, and Defendant points to no evidence suggesting that it walls off its analysts from those interested in firm finances, penalizes inaccurate deci-sionmaking, or took any particular.measure in this case to promote independent [1367]*1367and accurate claims assessment.18

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Bluebook (online)
66 F. Supp. 3d 1361, 2014 U.S. Dist. LEXIS 168639, 2014 WL 6895951, Counsel Stack Legal Research, https://law.counselstack.com/opinion/reiling-ex-rel-bjwr-v-sun-life-assurance-co-of-canada-ksd-2014.