Moore v. Unum Provident Corp. , 116 F. App'x 416 ( 2004 )

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 03-2311
ROSANNE MOORE,
Plaintiff - Appellee,
versus
UNUM PROVIDENT CORPORATION,
Defendant - Appellant.
No. 04-1044
ROSANNE MOORE,
Plaintiff - Appellee,
versus
UNUM PROVIDENT CORPORATION,
Defendant - Appellant.
Appeals from the United States District Court for the District of
South Carolina, at Florence. Terry L. Wooten, District Judge.
(CA-01-4185-4-25)
Argued: September 29, 2004 Decided: November 10, 2004
Before MICHAEL and MOTZ, Circuit Judges, and Roger W. TITUS, United
States District Judge for the District of Maryland, sitting by
designation.
Vacated in part, affirmed in part, and remanded by unpublished per
curiam opinion.
ARGUED: Theodore DuBose Willard, Jr., MONTGOMERY, PATTERSON, POTTS
& WILLARD, L.L.P., Columbia, South Carolina, for Appellant. Kevin
Mitchell Barth, HARWELL, BALLENGER & DEBERRY, Florence, South
Carolina, for Appellee.
Unpublished opinions are not binding precedent in this circuit.
See Local Rule 36(c).
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PER CURIAM:
Unum Provident Corporation (Unum) appeals the district
court’s award of life insurance benefits and attorney’s fees to
Rosanne Moore in connection with her husband’s death. Mrs. Moore’s
suit for accidental death benefits under the Unum policy provided
by her employer is governed by the Employee Retirement Income
Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. We vacate
the district court’s award of judgment to Mrs. Moore because the
court misapplied the standard for determining whether her husband’s
death was accidental. The district court was correct, however, in
concluding that the evidence in the administrative record was
insufficient to establish that the policy’s controlled substances
provision applies. Because the judgment in favor of Mrs. Moore is
being vacated, we also vacate her award of attorney’s fees. The
case will be remanded for further proceedings consistent with this
opinion.
I.
On October 22, 1998, between 4:00 and 4:30 a.m., William
E. Moore (Moore) entered the home of his girlfriend, Lisa McFerrin,
without permission. Moore, who was carrying a pistol, went to
McFerrin’s bedroom where he found her and her invited guest, Jerry
Sayles. An altercation between Moore and Sayles ensued, and Sayles
wrested the gun from Moore and beat him with it. Moore died from
cardiac arrhythmia due to the stress of the beating. A toxicology
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report revealed that Moore was under the influence of
methamphetamine at the time of his death.
Moore’s wife, Rosanne Moore (Mrs. Moore), had insurance
coverage for accidental injury or death under a policy maintained
by her employer. Moore, her husband, was a covered spouse under
the policy. The policy covered losses, including loss of life,
that “result directly and independently of all other causes from
accidental bodily injury.” J.A. 62. A rider excluded coverage for
“injury caused by or contributed to directly or indirectly by: the
Insured being under the influence of a ‘controlled substance.’”
J.A. 91. Moore’s death prompted Mrs. Moore to file a claim for
accidental death benefits under the policy. Unum (the insurance
company) denied the claim on two separate grounds: (1) that
Moore’s death was not accidental because he was the “aggressor in
an altercation that led to his death,” J.A. 112, and (2) that
coverage was excluded because Moore was under the influence of a
controlled substance, methamphetamine, which either caused or
contributed to his death. Mrs. Moore pursued an internal appeal
with Unum, and the company’s ERISA appeals committee confirmed the
denial of her claim. Mrs. Moore then filed an action to recover
under the policy in South Carolina state court, and Unum removed
the case (on grounds of complete preemption under ERISA) to the
United States District Court for the District of South Carolina.
The parties cross-moved for summary judgment. Thereafter, the
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parties stipulated that the district court “should decide the case
based on the record before the Court.” J.A. 351 n.2. After
conducting a de novo review of the administrative record, the
district court awarded judgment to Mrs. Moore, concluding that she
was entitled to death benefits under the policy. The court also
awarded attorney’s fees to Mrs. Moore. Unum appeals, raising three
issues.
II.
Unum first argues that the district court applied the
wrong legal standard when it concluded that Moore’s death was an
accident within the meaning of the insurance policy. We review
this issue of policy (or contract) interpretation de novo.
Johannssen v. Dist. No. 1-Pac. Coast Dist., 292 F.3d 159, 171 (4th
Cir. 2002). Because the policy in this case is regulated by ERISA,
we are “guided by federal substantive law.” Baker v. Provident
Life & Accident Ins. Co., 171 F.3d 939, 942 (4th Cir. 1999). In
determining the principles of federal law that govern contract
interpretation under ERISA, we may, of course, look to state law
for guidance. Id.When an insured dies as a result of the intentional act
of another, the death is considered accidental “if the insured is
innocent of aggression, or wrongdoing, or even if he is the
aggressor, if he could not reasonably anticipate bodily injury
resulting in death to himself at the hands of another.” New York
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Life Ins. Co. v. Murdaugh, 94 F.2d 104, 107 (4th Cir. 1938)
(internal quotation marks and citation omitted). The district
court concluded that Moore’s death was accidental because, even if
Moore was the aggressor, he would not have anticipated “the cardiac
arrhythmia which resulted in death as highly likely to occur under
the circumstances.” J.A. 352.
The district court misapplied the standard. When an
altercation ends in the death of the aggressor, the death is not an
accident if the aggressor could reasonably anticipate that he might
die at the hands of his opponent. The aggressor does not have to
anticipate the exact cause of his death. The question, in other
words, is whether it is reasonably foreseeable to the aggressor
that he is triggering a chain of events that could result in his
death, regardless of the exact cause. A case cited by Mrs. Moore,
Rooney v. Mutual Benefit Health and Accident Association, 170 P.2d
72 (Ca. App. 1946), illustrates the role that the aggressor’s
foreseeability plays in determining whether his death resulting
from an altercation is accidental. In Rooney the insured got into
an argument with a stranger in a restaurant, and the insured
invited the stranger outside to settle the matter. A fistfight
ensued, and no deadly weapons were involved. The insured, who was
the aggressor, died after hitting his head on a concrete sidewalk
during the fight. The insured’s death was accidental, the
California Court of Appeals held, because he did not have reason to
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believe his “fistic encounter would result in death.” Id. at 74.
Thus, under Rooney, when the aggressor can reasonably expect that
his death could be the result of the altercation he initiates, his
death is not accidental. Id. In sum, the aggressor’s death does
not fit the accidental category if he can reasonably anticipate
that his death could result from the altercation. The aggressor
does not have to forsee the exact cause of death.
Here, Moore’s death was not an accident simply because he
would not have reasonably anticipated the exact cause, cardiac
arrhythmia. Moore entered his girlfriend’s house uninvited at
about 4:00 a.m., and carrying his handgun, he went into her bedroom
where she was with another man who was her guest. Moore’s
resulting death was not an accident “if he could [have] reasonably
anticipate[d] bodily injury resulting in death to himself at the
hands of another.” New York Life Ins. Co. v. Murdaugh, 94 F.3d
104. We therefore vacate the district court’s determination that
Moore’s death was an accident, and we remand for the proper
application of the standard set forth in New York Life Insurance
Company v. Murdaugh.
III.
Unum argues second that the district court erred in
concluding that Moore’s death was not directly or indirectly caused
by his use of methamphetamine. This meant that Unum was not
excused from the payment of death benefits because of the policy’s
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controlled substances exclusion.
The toxicology tests of Moore’s blood showed he had
between 2.1 mg/L and 3.9 mg/L of methamphetamine in his system at
the time of his death. A forensic review by Dr. Kristin G. Sweeney
provides the only medical analysis in the administrative record of
the relationship between Moore’s methamphetamine use and his death.
Dr. Sweeney’s report discusses in general terms the link between
the use of stimulants and cardiac arrhythmia. She concludes that
“chronic cocaine and/or methamphetamine abuse could contribute to
a cardiomyopathy” and that the “known pharmacologic effects of
methamphetamine, particularly at this toxic level, could be
expected to acutely exacerbate any pre-existing cardiovascular
disease.” J.A. 126-27.
In the district court proceedings, Unum sought to bolster
Dr. Sweeney’s report by tendering the deposition of Dr. Joel
Sexton; Dr. Sexton was deposed in a separate proceeding after the
administrative record in this case had closed. Dr. Sexton had
already submitted a report in this case; however, his original
conclusions, which were in the administrative record and which were
made without an examination of the toxicology results, did not
mention methamphetamine. In the tendered deposition, Dr. Sexton
testified that after considering the toxicology report, he had
concluded methamphetamine was a cause of Moore’s death. Mrs. Moore
objected to the submission of the Sexton deposition, and the
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district court excluded it, holding that it was “improper
supplemental evidence.” J.A. 355.
In Quesinberry v. Life Insurance Company of North
America, 987 F.2d 1017 (4th Cir. 1993), we discussed when it is
proper for a district court, in conducting a de novo review of an
ERISA benefits claim, to consider evidence that was not part of the
record before the plan administrator. As a general rule, the court
should consider only the administrative record that was before the
administrator. “Exceptional circumstances,” however, “may warrant
an exercise of the [district] court’s discretion” to consider
additional evidence when it is “necessary for resolution of a
benefit claim.” Id. at 1026-27. Unum argues that two of the
exceptional circumstances mentioned in Quesinberry required the
district court to consider Dr. Sexton’s testimony: (1) the
analysis in Dr. Sexton’s deposition could not have been presented
during the administrative process and (2) the controlled substances
exception in the policy requires the consideration of a complex
medical question that should be resolved with the assistance of
actual testimony. Dr. Sexton’s deposition does not fall within
either of these exceptions.
First, although Dr. Sexton was deposed after Unum, the
plan administrator, reached its decision, the toxicology report
showing that Moore was under the influence of methamphetamine was
available before the administrative record was closed. As the
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district court found, Unum could have submitted the toxicology
report to Dr. Sexton, or another expert, for an opinion before the
administrative record closed. For whatever reason, Unum failed to
take this step. As we observed in Quesinberry, there is a
difference between evidence that could have been mustered during
the administrative process and evidence that simply could not have
been developed in time. In other words, “if the evidence . . . is
simply better evidence than the [party] mustered for the claim
review, then its admission is not necessary” in the district court.
Id. at 1027. Dr. Sexton’s analysis of the toxicology report is
simply better evidence than could have been, but was not, developed
and included in the administrative record.
Second, the role of methamphetamine in Moore’s death is
a medical question, but it is not so complex that it cannot be
resolved by review of the administrative record. This is not a
situation where additional information in the form of actual
testimony is necessary to “facilitate the understanding of complex
medical [issues] through an exchange of questions and answers
between experts, counsel, and the court.” Id. If Unum had
submitted for the administrative record a report from Dr. Sexton
analyzing the toxicology data on Moore, we are confident that the
doctor’s report would have been sufficiently understandable on
judicial review. In short, the district court did not abuse its
discretion in excluding Dr. Sexton’s deposition.
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Finally, we turn to the district court’s decision that
the controlled substance exclusion does not apply, a decision that
we review de novo. Id. at 1022. The district court concluded that
the evidence in the administrative record is insufficient to permit
a finding that Moore’s death was a direct or indirect result of
methamphetamine use. Dr. Sweeney’s opinion about the effects of
chronic use of methamphetamine or cocaine is not relevant because
there is no evidence that Moore was a chronic user of such drugs.
In addition, Dr. Sweeney’s opinion -- that the level of
methamphetamine in Moore’s system could have contributed to his
death by exacerbating a pre-existing cardiovascular disease -- is
too indefinite to support a finding that Moore’s death was a result
of methamphetamine use. We therefore affirm the district court’s
determination that there was not sufficient evidence to trigger the
controlled substances exclusion.
IV.
Finally, Unum appeals the award of attorney’s fees to
Mrs. Moore. After the district court granted judgment to Mrs.
Moore awarding her death benefits under the policy, the court
entered an order granting her motion for attorney’s fees under
ERISA, 29 U.S.C. § 1132(g). Because we are vacating the judgment
awarded to Mrs. Moore, we also vacate the order allowing her
attorney’s fees. The attorney’s fees issue may be reconsidered on
remand should that become appropriate.
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V.
In sum, we vacate the district court’s orders awarding
judgment and attorney’s fees to Rosanne Moore. We affirm the
district court’s conclusion that coverage cannot be denied under
the policy’s controlled substances exclusion. We remand for
reconsideration of whether or not William E. Moore’s death was an
accident under the standard discussed in part II of this opinion.
VACATED IN PART,
AFFIRMED IN PART,
AND REMANDED
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