Linda Grabowski v. Hartford Life & Accident Ins. ( 2018 )

UNPUBLISHED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Affirmed by unpublished per curiam opinion.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Unpublished opinions are not binding precedent in this circuit.
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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,
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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
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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
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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
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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
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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.
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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
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