John Guthrie v. Prudential Insurance Co of Ame

NOT PRECEDENTIAL
UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT
__________
No. 14-3282
__________
JOHN GUTHRIE, as Beneficiary of an Accidental Death Insurance Policy
Issued in the Name of Corey Guthrie, deceased,
Appellant
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
__________
On Appeal from the United States District Court
for the District of New Jersey
(D.C. Civil No. 2:12-cv-07358)
District Judge: Honorable Jose L. Linares
Submitted Under Third Circuit LAR 34.1(a)
March 17, 2015
BEFORE: FUENTES, RENDELL**, and BARRY, Circuit Judges
(Filed: September 2, 2015)
__________
OPINION*
__________
**
The Honorable Marjorie O. Rendell assumed senior status on July 1, 2015.
*
This disposition is not an opinion of the full Court and pursuant to I.O.P. 5.7 does not
constitute binding precedent.
1
FUENTES, Circuit Judge.
John Guthrie challenges the District Court’s decision granting summary judgment
on his denial of benefits claim brought under ERISA.1 For the reasons set forth below,
we affirm.2
I.
In the early morning hours of August 6, 2010, Corey Guthrie died following a
single-vehicle accident in the state of Virginia. He was last seen alive leaving a
restaurant and bar about a mile from the crash. Police were dispatched to the scene at
approximately 12:59 a.m. and reported that Corey Guthrie ran his motorcycle off the road
toward an embankment. The road was dry, had no defects, and there was no adverse
weather that night. Corey Guthrie was taken to the hospital and pronounced dead at 1:37
a.m. A toxicology report completed after the accident stated that his blood alcohol
concentration (“BAC”) was 0.14% and his vitreous humour alcohol level was 0.13%.3
The legal blood alcohol limit in Virginia is 0.08%.4
At the time of the accident, Corey Guthrie was employed by CACI International,
Inc. and received insurance coverage for “Accidental Death and Dismemberment,” an
insurance policy issued by Prudential. The plan provided for coverage in the event of
1
29 U.S.C. § 1001 et seq.
2
We have jurisdiction over this appeal pursuant to 28 U.S.C. § 1291. The District Court
had jurisdiction pursuant to 28 U.S.C. § 1331. Because we write for the parties and the
District Court, we recite only those facts necessary to our conclusion.
3
The vitreous humour is the clear gel that fills the space between the lens and the retina
of the eyeball. The vitreous humour is of forensic interest because the in vivo serum
levels of alcohol, drugs, and other substances can be estimated from the vitreous humour.
4
Va. Code Ann. § 18.2-266.
2
accidental death, with a benefit amount of $270,000. As the sole beneficiary, John
Guthrie (Corey Guthrie’s father) filed a claim under the policy after his son’s death.
Prudential denied the claim due to an exclusion in the policy that was triggered if, at the
time of the accident, the operator of the vehicle was legally intoxicated. Based on reports
from the accident, Prudential concluded that Corey Guthrie was above the legal blood
alcohol limit when he crashed.
John Guthrie (“Guthrie”) appealed the decision, asserting that Prudential could not
determine his son’s blood alcohol level at the time of the accident. Because of this,
Guthrie argued, Prudential could not meet its burden of proving that the policy exclusion
applied. In response, Prudential contacted the Commonwealth of Virginia Department of
Forensic Science that had collected Corey Guthrie’s blood and vitreous humour samples.5
Prudential was informed that in order to receive the requested information, it would need
to subpoena the Commonwealth and pay a service fee to speak with any of the
department’s employees. Additionally, Prudential contacted the Medical Examiner’s
Office to request the same information but received no response.
As a result, Prudential referred the matter internally and requested that Albert A.
Kowalski, M.D., review the case to determine whether he could discern Corey Guthrie’s
blood alcohol content at the time of the accident. Dr. Kowalski’s analysis consisted of a
“retrograde extrapolation” in which he declared the rate of elimination could be
5
Prudential requested the date and time the samples were drawn, the date and time tests
were performed, whether the chain of custody was established and maintained, the
department’s opinion as to whether the BAC of 0.14% reflected Corey Guthrie’s BAC
between midnight and 1:00 a.m., and the department’s opinion as to what Corey
Guthrie’s BAC would have been during that time period.
3
determined within a reasonable degree of medical certainty. He noted that the rate of
absorption could not be determined because there were several unknown variables, which
included the type of beverage Corey Guthrie had been consuming prior to the accident,
quantity of beverage, time of last drink, and quantity of food ingested. Dr. Kowalski
estimated the blood alcohol level using the vitreous humour alcohol level of .13% from
the toxicology report and determined the range to be .10% - .12%. He added that at this
level, Corey Guthrie would have experienced significant impairment of motor skills,
judgment, speech, balance, vision, reaction time and hearing, and that, at this level, the
risk of a single-vehicle fatal car crash increases to 48 times that of a driver who had not
consumed alcohol. Dr. Kowalski concluded that Corey Guthrie’s physical impairments
led to “a direct causal connection between the insured’s level of intoxication and the
motorcycle accident of 08/06/10 and his death.”6 After reviewing the information,
Prudential denied Guthrie’s appeal.
The District Court determined that Prudential’s denial of the claim due to Corey
Guthrie’s intoxication at the time of his death was supported by substantial evidence in
the record. The District Court explained that Guthrie did not present any evidence
suggesting that his son was not legally intoxicated at the time of the accident. In the
absence of such evidence, the District Court held Prudential reasonably relied on Dr.
Kowalski’s analysis in assessing the claim for accidental death benefits and that the
decision was neither arbitrary nor capricious. The District Court granted Prudential’s
motion for summary judgment and denied Guthrie’s motion. This appeal followed.
6
App. A167; A237.
4
II.
When reviewing a grant of summary judgment, we apply the same standard as the
District Court. Moreover, our review of an appeal from entry of summary judgment is
plenary.7 We may affirm the District Court’s decision if “the moving party is entitled to
judgment as a matter of law, with the facts reviewed in the light most favorable to the
non-moving party.”8 “We review a decision denying benefits under an arbitrary and
capricious standard of review where, as here, the administrator has discretionary
authority to determine eligibility for benefits, and, we will affirm an administrator’s
decision unless “it is without reason, unsupported by substantial evidence or erroneous as
a matter of law.”9 The scope of this review is deferential to the benefits provider, and
“the court is not free to substitute its own judgment for that of the defendants in
determining eligibility for plan benefits.”10
On appeal, Guthrie asserts two arguments: (1) that the District Court erred by
failing to give weight to his structural conflict-of-interest argument due to Prudential’s
role as both claim payer and claim evaluator; and (2) that the District Court erred by
failing to assess Prudential’s burden of proof in light of flawed science and questionable
evidence. We address each claim in turn.
A.
7
See Vitale v. Latrobe Area Hosp., 420 F.3d 278, 281 (3d Cir. 2005).
8
Miller v. Am. Airlines, Inc., 632 F.3d 837, 844 (3d Cir. 2011) (citation and internal
quotations omitted).
9
Doroshow v. Hartford Life & Accident Ins. Co., 574 F.3d 230, 233-34 (3d Cir. 2009).
10
Id. (quoting Abnathya v. Hoffmann-La Roche, Inc., 2 F.3d 40, 45 (3d Cir. 1993)).
5
Guthrie argues that the District Court failed to adequately consider Prudential’s
role as both claim payer and claim evaluator. We disagree. In Metropolitan Life
Insurance Co. v. Glenn, the Supreme Court acknowledged that this type of dual role
“creates a conflict of interest” and that conflict should be considered “as a factor in
determining whether the plan administrator has abused its discretion in denying
benefits.”11 Here, the District Court examined the inherent conflict of interest as a factor.
In doing so, it, however, recognized that “not every conflict of this sort will be
significant” and found “no evidence in the record to accord this factor special
emphasis.”12 It then examined each of Guthrie’s over-arching theories, namely that: (1)
Prudential did not establish a chain of custody from the toxicologist who interpreted the
results of the test; (2) Prudential could have, but did not obtain an independent opinion;
and (3) Dr. Kowalski’s retrograde extrapolation analysis was unreliable. The District
Court concluded that Guthrie did not submit any evidence regarding the structure of
Prudential’s operations and there was no sign of a pattern of bias in the investigation. We
agree with the District Court’s conclusion.
The District Court found no reason that Prudential should not have relied on the
toxicology report and no legal authority to support Guthrie’s position that proof of chain
of custody was necessary. Prudential played no role in the administration of the test.
Guthrie fails to demonstrate that the test was inaccurate or compromised, and he fails to
11
Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008).
12
App. A19-20.
6
cite any legal authority indicating the contrary. Guthrie also neglects to illustrate how the
data points stemming from the chain of custody are pivotal to his argument.
Furthermore, Guthrie argues Prudential’s failure to obtain an independent, outside
opinion merits great scrutiny. The record shows, and the District Court recognized as
sufficient, that Prudential attempted to obtain other opinions before issuing its decision.
Indeed, Guthrie did not argue Prudential defied its obligations as Plan administrator in
declining to subpoena the information and pay a fee for a third party’s opinion.
Prudential’s lack of corroboration did not increase its level of bias, as it attempted to
mitigate the circumstances by contacting outside departments.
Finally, Guthrie challenges the reliability of the retrograde analysis performed by
Dr. Kowalski. The District Court noted that Guthrie relied on several cases arising in the
criminal context, and that Prudential was not bound by the standard of proof in a criminal
context. Guthrie, however, supplied no evidence to suggest that the analysis was
unreliable or inadequate, nor did he offer a plausible alternative to retrograde
extrapolation. Without convincing evidence otherwise, the District Court correctly
concluded that Dr. Kowalski’s retrograde analysis was based on substantial evidence and
Prudential was reasonable to rely on it.
Thus, we hold that the District Court gave sufficient consideration to Prudential’s
conflict-of-interest. Because Guthrie failed to present evidence that Prudential’s
investigation was tainted or that an analysis to determine Corey Guthrie’s BAC at the
time of the crash could have been done another way, Prudential properly relied Dr.
7
Kowalski’s analysis. There is no evidence that Prudential was motivated by self-interest
in its benefits denial decision.
B.
Guthrie also asserts that the District Court’s review was overly deferential to the
Plan administrator. We must determine if the decision was supported by “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” 13 The
District Court held that the evidence in the record substantially supported Prudential’s
finding that Corey Guthrie was legally intoxicated at the time of the accident and that the
intoxication caused or contributed to the accident and resulting death. We agree with this
conclusion.
The police report stated that Corey Guthrie ran off the road towards an
embankment on a dry road with no adverse weather conditions. Corey Guthrie was last
seen alive drinking alcohol at a local bar. According to the toxicology report, Corey
Guthrie’s blood alcohol level was 0.14% and his vitreous humour alcohol level was
0.13%. Furthermore, Dr. Kowalski opined that Corey Guthrie’s blood alcohol level at
the time of the accident could be determined within a reasonable degree of medical
certainty through retrograde extrapolation. He concluded that Corey Guthrie’s blood
alcohol level was between 0.10 and 0.12% at the time of the accident.
Based on this evidence, we hold that the District Court did not err in affirming
Prudential’s denial of coverage.
III.
13
Fleisher v. Standard Ins. Co., 679 F.3d 116, 121 (3d Cir. 2012)
8
For all the reasons stated above, we affirm the District Court’s order granting
summary judgment.
9