Buzzanga v. Life Ins. Co. of N. Amer., 2013 U.S.Dist.LEXIS 1348 (E.D.Mo. January 4, 2013) (Issue: Scope of Review).

This case involves an accidental death claim asserted after the plaintiff’s husband was killed in a single-car accident. The insurer denied the claim, maintaining the decedent’s blood alcohol level was above the legal limit and therefore disqualified the decedent’s eligibility for benefits despite the absence of any plan provision excluding alcohol-related deaths. The court analyzed the issues in light of Wickman v. Northwestern Nat’l Ins. Co., 908 F.2d 1077 (1st Cir. 1990) and McClelland v. Life Ins. Co. of North America, 679 F.3d 755 (8th Cir. 2012), which dealt with the identical issues, and ruled in favor of the claimant. In addition to the claim file, the court took into consideration the deposition of the regional claims manager, Brian Billeter, along with additional information that was submitted following a remand.

The insurer maintained that since the decedent would have been aware of the risk involved in operating a vehicle under the influence of alcohol, there was no accident and therefore no benefits due. The court disagreed.

First, the court ruled that LINA improperly refused to accept additional material submitted for review on remand. The court cited two similar cases in which the insurer had accepted additional evidence on remand: Loberg v. Cigna Group Ins., No. 8:09CV280, 2012 WL 3527718, at *4 (D. Neb. Aug. 14, 2012) (on remand, Cigna considered report of independent forensic toxicologist); and McClelland v. Life Ins. Co/ of No. America, No. 08-4945 (MJD/AJB), 2010 WL 3893695, at *5 (D. Minn. Sept. 30, 2010) (on remand, LINA considered plaintiff’s additional evidence). Hence, the court concluded, “Because plaintiff gave LINA the opportunity to consider this additional evidence in the first instance, the Court may properly consider it on abuse of discretion review.”

The court then focused on Wickman, which requires consideration of two factors: (1) a determination of the insured’s actual expectations, and (2) a determination of whether the insured’s actual expectations were reasonable from an objective viewpoint. The court also noted, “The Wickman test requires, if possible, a subjective look at the insured’s state of mind.” McClelland, 679 F.3d at 760. An insurer may not rely on a “categorical conclusion that those who drink and drive should reasonably expect to be killed.” Id. Based on those principles, the court found that LINA failed to properly apply the Wickman test by failing to “reasonably analyze” the decedent’s subjective expectations. The court also quoted extensively from the regional claim manager’s deposition. Brian Billeter testified as follows:

Q: What was different in your reconsideration on remand?
A: I don’t really recollect exactly what the remand order said, but there was some additional information in the remand order.

Q: Did you apply a different definition of accident?
A: I believe we applied the same definition of accident as a sudden unforeseeable external event.

Q: So in your decision on remand, the definition of accident that you applied was a sudden unforeseen external event?
A: That’s correct.

Q: Is a sudden unforeseen external event . . . different than an analysis based upon highly likely to occur?
A: I think in this case we take a look at the component of unforeseen and determine whether or not something from an objective standpoint is reasonably likely to occur.

Q: Do you know what the Wickman standard is?
A: I believe it lays down the requirements for looking at whether or not an individual would have an expectation of harm with regard to their actions.

Q: And is that different from a foreseeability analysis in your opinion?
A: No. I think it is the same general type of idea that foreseeability becomes the reasonable expectation of harm as a result of your own actions.

Tr. 50-52.

Billeter later testified that the crash would have been classified as an accident if Mr. Robinett’s blood alcohol level were zero even if he was traveling too fast on a wet road. Tr. 71-72. He also testified that “driver inattention in and of itself is not a basis for deeming something to be non-accidental in nature.” Tr. 74. He also testified that if he were convinced that a driver’s intoxication was the only cause of the accident, “then we may determine that the claimant has not suffered an accident . . .” Tr. 77. This testimony confirms that LINA once again applied aper se exclusion for deaths in which the driver was intoxicated.

Although LINA maintained that it was impossible to determine what the decedent subjectively believed, the court found the evidence showed that he expected to survive his drive and meet his wife. Hence, the court found an accidental death, and concluded, “In light of the conflict of interest and LINA’s failure to consider the evidence before it, the Court concludes that LINA abused its discretion in denying benefits, because it improperly applied the Wickman standard and because substantial evidence does not support its decision.”

Related Articles

How Do I Know if My Benefit Plan Is Self-Funded?

How Do I Know if My Benefit Plan Is Self-Funded?

When the term “self-funded” is used in relation to employer-sponsored benefit plans, the term usually refers to what are known as “welfare” benefits. ERISA does not use the term “welfare” to mean public assistance. Instead, the term relates to benefits provided for the employee’s welfare; and is defined by the statute to mean […]

What Is ERISA?

What Is ERISA?

ERISA, an acronym for the Employee Retirement Income Security Act of 1974,1 is one of the most important federal laws ever passed by Congress, but hardly anyone knows what it is or what it does. […]

ERISA Ruling Shows Lax Enrollment Practices Can Be Costly

ERISA Ruling Shows Lax Enrollment Practices Can Be Costly

A life insurance decision issued by the U.S. Court of Appeals for the Eighth Circuit may be summed up by quoting a single sentence from the opinion: “Misleading an [Employee Retirement Income Security Act]-plan participant has consequences.” Skelton v. Reliance Standard Life Insurance Co.[1] teaches how lax benefit enrollment practices can be costly. […]

How Can I Tell If My Benefit Plan Is Governed by ERISA?

How Can I Tell If My Benefit Plan Is Governed by ERISA?

ERISA is an acronym for the federal Employee Retirement Income Security Act of 1974. Most people have never heard of ERISA, but its comprehensiveness impacts the vast majority of American workers and their dependents. The original intent behind ERISA’s enactment was to remedy pension plan abuses; however, just prior to Congress’ passage of the ERISA law, the scope […]