Baker v. Provident Life ( 1999 )

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
THOMAS BAKER,
Plaintiff-Appellant,
v.
No. 97-2756
PROVIDENT LIFE & ACCIDENT
INSURANCE COMPANY,
Defendant-Appellee.
Appeal from the United States District Court
for the Western District of North Carolina, at Charlotte.
Graham C. Mullen, Chief District Judge.
(CA-979-124-3-MU)
Argued: December 1, 1998
Decided: February 19, 1999
Before WILKINSON, Chief Judge, TRAXLER, Circuit Judge, and
HILTON, Chief United States District Judge for the Eastern
District of Virginia, sitting by designation.
_________________________________________________________________
Affirmed by published opinion. Chief Judge Wilkinson wrote the
opinion, in which Judge Traxler and Chief Judge Hilton joined.
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COUNSEL
ARGUED: Sara Rich Lincoln, HEDRICK, EATMAN, GARDNER
& KINCHELOE, L.L.P., Charlotte, North Carolina, for Appellant.
Christopher George Smith, SMITH, ANDERSON, BLOUNT, DOR-
SETT, MITCHELL & JERNIGAN, L.L.P., Raleigh, North Carolina,
for Appellee. ON BRIEF: Scott M. Stevenson, HEDRICK, EAT-
MAN, GARDNER & KINCHELOE, L.L.P., Charlotte, North Caro-
lina, for Appellant. Mark A. Ash, SMITH, ANDERSON, BLOUNT,
DORSETT, MITCHELL & JERNIGAN, L.L.P., Raleigh, North Car-
olina, for Appellee.
_________________________________________________________________
OPINION
WILKINSON, Chief Judge:
Appellant Thomas Baker challenges a denial of health care benefits
by his insurer appellee Provident Life and Accident Insurance Com-
pany. Baker incurred substantial medical expenses as a result of an
automobile accident in which he was driving drunk and collided with
another vehicle, killing the driver. Baker pled guilty to involuntary
manslaughter, a felony under North Carolina law. Provident denied
Baker benefits under a clause in his policy that excluded coverage for
injuries sustained due to one's voluntary participation in a felony.
Baker contends that committing involuntary manslaughter can never
constitute voluntary participation in a felony. Provident argues that
because Baker's drinking and driving were voluntary, so was his
commission of involuntary manslaughter. Baker brought suit under
ERISA in the United States District Court for the Western District of
North Carolina seeking benefits. The district court granted Provi-
dent's motion for summary judgment. We now affirm.
I.
On December 30, 1995, Baker was driving while intoxicated. He
attempted to pass a car in front of him by crossing over the double
yellow line into oncoming traffic. Baker's car collided head-on with
a car driven by Rita Castrillion, killing her. Shortly after the accident,
Baker's blood alcohol content registered .286 -- over three times the
legal limit in North Carolina. N.C. Gen. Stat. § 20-138.1. Baker pled
guilty to, among other things, involuntary manslaughter and driving
while impaired. Under North Carolina law, involuntary manslaughter
is a felony, id. § 14-18, and driving while impaired is a misdemeanor,
id. § 20-138.1.
2
Baker suffered severe injuries as a result of the accident and
incurred $179,295 in medical expenses. At the time of the accident,
Baker was enrolled in a group health care plan governed by the
Employee Retirement Income Security Act (ERISA), 29 U.S.C.
§ 1001 et seq. Baker submitted his medical expenses to Provident Life
and Accident Insurance Company, the claims fiduciary of the plan.
Baker's plan provided that "Provident will have exclusive discretion
and authority to carry out all actions involving claims procedures
explained in [the insured's] booklet" as well as "exclusive discretion
and power to grant and/or deny any and all claims for benefits and
determine any and all issues relating to eligibility for benefits." Most
critically, the plan provided that benefits will not be paid for "treat-
ment of an [i]njury or [i]llness which is due to voluntary participation
in a felony." Pursuant to this provision, Provident denied benefits,
reasoning that Baker voluntarily participated in a felony.
Baker then brought suit under 29 U.S.C. § 1132(a)(1)(B) claiming
that Provident wrongfully denied him benefits. The district court
granted summary judgment to Provident, holding that Baker, by
pleading guilty to involuntary manslaughter, "pleaded guilty to will-
fully violating the drunk driving statute and thereby causing a death."
The district court then held that Baker's conduct, which "caused the
death -- and [which] resulted in a felony-- was therefore at least
voluntary." Baker appeals.
II.
When an ERISA plan reserves for the plan administrator discretion
to determine a claimant's eligibility for benefits or to construe the
terms of the plan, a court will review the administrator's decision to
deny benefits under an abuse of discretion standard. Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Under this standard,
we will not disturb any reasonable interpretation by the administrator.
Doe v. Group Hospitalization & Med. Servs., 3 F.3d 80, 85 (4th Cir.
1993). When the administrator also has a financial interest in the out-
come of its benefits decision or interpretation of the plan, however,
"this deference will be lessened to the degree necessary to neutralize
any untoward influence resulting from the conflict." Id. at 87.
Because Provident both insures and administers the payment of bene-
3
fits under Baker's plan, we will view its denial under this less defer-
ential standard.
When interpreting the benefits provisions of ERISA regulated
insurance plans, courts are guided by federal substantive law. See
United McGill Corp. v. Stinnett, 154 F.3d 168, 171 (4th Cir. 1998);
Wickman v. Northwestern Nat'l Ins. Co., 908 F.2d 1077, 1084 (1st
Cir. 1990). The language of the plan itself, of course, is paramount
in this endeavor. Lockhart v. United Mine Workers 1974 Pension
Trust, 5 F.3d 74, 78 (4th Cir. 1993). Baker's plan excludes coverage
for the "treatment of an [i]njury or [i]llness which is due to voluntary
participation in a felony." Baker's plan does not, however, define the
term "voluntary." To interpret an undefined term, courts may refer-
ence a number of sources including state law, Wickman, 908 F.2d at
1084, and the law of other federal courts, see Stinnett, 154 F.3d at
172. Both state and federal law support Provident's reading of the
term "voluntary" and hence the reasonableness of its plan interpreta-
tion.
Baker argues that because North Carolina law classifies driving
under the influence as a misdemeanor, he did not voluntarily partici-
pate in a felony. He maintains that although he voluntarily drove
drunk, he did not voluntarily kill Rita Castrillion."The very nature of
the crime of involuntary manslaughter," he contends, "centers around
the involuntary actions of the person charged." Baker argues that in
order for him to voluntarily participate in a felony under the terms of
his policy, it is necessary that he possess a specific intent to kill.
In the closely analogous area of accidental death benefits cases,
North Carolina courts and a majority of federal courts have rejected
Baker's reasoning. Accidental death benefits cases present the same
question as the one we face here: What level of expectation is neces-
sary for the consequences of a voluntary act to be voluntary? Must the
actor specifically intend the consequences of that act, or is it enough
that a reasonable person would foresee those consequences?
The North Carolina Supreme Court has answered this very ques-
tion. In Allred v. Prudential Ins. Co. of Am. , 100 S.E.2d 226 (N.C.
1957), the insured laid down in the middle of the highway. Despite
his friends' exhortations to move, the insured remained in the middle
4
of the highway in the face of oncoming traffic. A passing automobile
ran over him. In holding that the insured's death was not an accident,
the North Carolina Supreme Court stated the general rule that a "death
which is the natural and probable consequence of an act or course of
action is not an accident nor is it produced by accidental means, and,
if not the result of actual design, [the] insured must be held to have
intended the result." Id. at 230 (internal quotation marks omitted).
A majority of federal courts have applied this rule to deaths result-
ing from drunk driving accidents. See Cozzie v. Metropolitan Life Ins.
Co., 140 F.3d 1104, 1110 (7th Cir. 1998); Walker v. Metropolitan Life
Ins. Co., 24 F. Supp. 2d 775, 782 (E.D. Mich. 1997); Schultz v. Met-
ropolitan Life Ins. Co., 994 F. Supp. 1419, 1422 (M.D. Fla. 1997);
Nelson v. Sun Life Assurance Co. of Canada, 962 F. Supp. 1010, 1013
(W.D. Mich. 1997); Miller v. Auto-Alliance Int'l, Inc., 953 F. Supp.
172, 176 (E.D. Mich. 1997). But see American Family Life Assurance
Co. v. Bilyeu, 921 F.2d 87, 89 (6th Cir. 1990). For example, in Cozzie,
the insured was killed in a single-car accident. At the time of the acci-
dent the insured's blood alcohol content was twice the legal limit. The
insured's spouse argued that his death was an accident under his pol-
icy. In rejecting that view, the Seventh Circuit upheld the administra-
tor's determination that "a death that occurs as a result of driving
while intoxicated, although perhaps unintentional, is not an ``accident'
because that result is reasonably foreseeable." Cozzie, 140 F.3d at
1110.
We hold that this same rule applies to the exclusion in Baker's pol-
icy for voluntary participation in a felony. Baker voluntarily drank too
much. He voluntarily got behind the wheel of his automobile while
drunk. And he voluntarily crossed the center line into oncoming traf-
fic. No one forced Baker to drink too much, to drive while drunk, or
to crash headlong into Rita Castrillion. The dangers of driving while
intoxicated are plain. Baker cannot now be heard to claim that he was
unaware that his behavior threatened his own life and those of other
motorists. Inasmuch as a reasonable person in Baker's position would
have known that death or serious injury was a reasonably foreseeable
result of driving while intoxicated, Baker's participation in the felony
of involuntary manslaughter was voluntary.
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Baker contends that this reading of the word voluntary is unreason-
able because it means that Provident's obligation to pay benefits
depends on the result of the accident. Baker argues that this rule
means, for example, that Provident would pay his health care
expenses if he hit a tree -- which is not a felony under North Carolina
law -- instead of Castrillion. But Provident's decision rests on a dis-
tinction that already is present in North Carolina law. North Carolina,
like every other state, attaches different consequences when one
causes the death of another than when one does not. If Baker had sim-
ply hit a tree, he would not have committed a felony. Baker does not
and cannot argue that this underlying distinction is unreasonable.
Similarly, it is not unreasonable for Provident to use that distinction
in its benefits determinations.*
III.
When Baker drank too much and decided to drive his car, he
should have reasonably foreseen that his actions might lead to the
death of another. Baker, therefore, voluntarily participated in the fel-
ony to which he later pled guilty. The judgment of the district court
is
AFFIRMED.
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*Baker also claims that the district court abused its discretion when it
converted Provident's motion for judgment on the pleadings into a sum-
mary judgment motion. Because Baker had a reasonable opportunity to
submit additional pertinent materials, we hold that the district court did
not abuse its discretion in converting Provident's motion.
6