Sanchez v. Life Insurance Co. of North America

Case: 09-51010 Document: 00511221927 Page: 1 Date Filed: 09/01/2010
IN THE UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT United States Court of Appeals
Fifth Circuit
FILED
September 1, 2010
No. 09-51010 Lyle W. Cayce
Clerk
TERRY S. SANCHEZ,
PlaintiffSAppellant
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA,
DefendantSAppellee
Appeal from the United States District Court
for the Western District of Texas
USDC No. 5:08-CV-527
Before CLEMENT, SOUTHWICK, and HAYNES, Circuit Judges.
PER CURIAM:*
This appeal arises out of the 2007 death of Hector Javier Sanchez in a one-
car accident. At the time of his death, Hector was covered under a group
accident policy underwritten by Life Insurance Company of North America
(LINA) and subject to ERISA. Hector’s wife, Terry Sanchez, submitted a claim
under this policy following his death. LINA denied her claim. After exhausting
her administrative remedies, Mrs. Sanchez filed suit under 29 U.S.C. §1132,
alleging that LINA abused its discretion when it denied her claim. On cross-
*
Pursuant to 5TH CIR . R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH CIR .
R. 47.5.4.
Case: 09-51010 Document: 00511221927 Page: 2 Date Filed: 09/01/2010
motions for summary judgment, the district court found for LINA. Mrs. Sanchez
appealed. We hold that LINA’s decision that Mr. Sanchez’s death did not
constitute a “Covered Accident” was not an abuse of discretion. Because this
decision is determinative of coverage, we need not reach Mrs. Sanchez’s question
regarding LINA’s application of the policy’s “Self-Inflicted Injury” exclusion.
Accordingly, we AFFIRM the district court’s entry of judgment in favor of LINA.
FACTS AND PROCEEDINGS
Mr. Sanchez’s employer provided a group accident policy (“Policy”) for its
employees. The Policy was underwritten by LINA and subject to the Employee
Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”). It
provided accidental death and dismemberment benefits when “the Covered
Person suffers a Covered Loss resulting directly and independently of all other
causes from a Covered Accident.” A “Covered Accident” is defined, in relevant
part, as a “sudden, unforeseeable, external event that results, directly and
independently of all other causes, in a Covered Injury or a Covered Loss” that
“is not contributed to by disease, Sickness, mental or bodily infirmity,” and “is
not otherwise excluded” by the Policy. The Policy excludes coverage for, among
other things, “intentionally self-inflicted Injury, suicide or any attempt thereat
while sane or insane.”
On the night of January 6, 2007, Mr. Sanchez died in a one-car crash.1 He
spent the evening with a friend, Joe Arthur Gutierrez, drinking and watching
a Dallas Cowboys’ football game. He departed at approximately 10:30 p.m. and
exhibited no signs of intoxication at that time. Forty-five minutes later, after
Mr. Sanchez had driven approximately twenty-three miles, five witnesses saw
1
We avoid the use of the generic term “accident” to prevent any confusion between it
and “Covered Accident,” a phrase defined in the Policy, the meaning of which is the central
dispute in this appeal.
2
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his vehicle swerve to the left shoulder, swerve sharply to the right, and roll over
several times. Sanchez was ejected from the vehicle. He was pronounced dead
at the scene shortly thereafter. The police report did not note any weather, road,
or vehicle conditions that may have contributed to the crash, nor did it indicate
that Mr. Sanchez had been driving irregularly or erratically prior to the crash.
The autopsy report and death certificate indicated that Mr. Sanchez had died as
a result of multiple injuries “sustained when the vehicle he was driving
reportedly lost control and rolled over.” Both ruled his death to be an “accident.”
A toxicology analysis of Mr. Sanchez’s blood and vitreous humor showed that,
around the time of his death, his blood ethanol was 0.174% and vitreous ethanol
was 0.170%.2
Following Mr. Sanchez’s death, Mrs. Sanchez filed a timely claim for
accidental death benefits under the Policy. LINA denied the claim, determining
that the crash was not a “Covered Accident,” as defined by the Policy, and that
the “intentionally self-inflicted Injury” exclusion precluded coverage. LINA
concluded that the crash was caused by Mr. Sanchez’s driving under the
influence of alcohol and that such a crash was not “unforeseen,” as required by
the Policy. It also determined that Mr. Sanchez’s voluntary decision to drink a
large amount of alcohol and drive contributed to the crash.
Mrs. Sanchez appealed these decisions, submitting an affidavit from Mr.
Gutierrez and asserting that statistics show that the majority of those who drive
under the influence of alcohol will make it to their destinations without incident.
In response, LINA obtained an opinion from a forensic consultant, Frederick
Fochtman, Ph.D., opining “with a reasonable degree of scientific certainty that
2
The State of Texas defines intoxication as “having an alcohol concentration of 0.08 or
more.” TEX. PENAL CODE ANN. § 49.01(2) (Vernon 2003).
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Mr. Sanchez’s BAC and resultant impairment was a causative factor in the
accident that resulted in his death.” LINA denied Mrs. Sanchez’s appeal for the
same two reasons it denied her claim.
After receiving LINA’s second denial of coverage, Mrs. Sanchez again
appealed. With her appeal, she submitted a report from a toxicologist, James
Garriott, Ph.D., stating that “the degree to which individuals are affected by
alcohol is largely a function of tolerance” and that Mr. Gutierrez’s affidavit
indicated that Mr. Sanchez had considerable alcohol tolerance. It further stated
that the use of alcohol does not constitute “an implicit attempt to harm
[oneself].” In response, LINA obtained a second report from Dr. Fochtman, who
concluded: “The obvious fact is that Mr. Sanchez did have an accident, and even
Dr. Garriott recognizes that a person with a BAC of 0.174% is at a greater risk
of having an accident due to impairment of driving-related skills. As I recall
from the report of the accident, there was no apparent reason provided for his
swerving his vehicle and rolling over, therefore a strong indication of driver
error.” LINA denied the second appeal.
Mrs. Sanchez then filed an ERISA claim against LINA under 29 U.S.C.
§ 1132, alleging that LINA had abused its discretion when it denied her claim.
On cross-motions for summary judgment, the district court conducted a thorough
analysis and concluded that LINA’s interpretation of a “Covered Accident” was
both legally correct and not an abuse of discretion. It further determined that
LINA’s interpretation of the self-inflicted injury exclusion was legally incorrect,
but not an abuse of discretion. Mrs. Sanchez appealed.
STANDARD OF REVIEW
Standard summary judgment rules control in ERISA cases. Vercher v.
Alexander & Alexander Inc., 379 F.3d 222, 225 (5th Cir. 2004). We review the
district court’s decision to grant a motion for summary judgment de novo,
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“applying the same standards as the district court.” Cooper v. Hewlett-Packard
Co., 592 F.3d 645, 651 (5th Cir. 2009).
DISCUSSION
As noted above, LINA denied coverage on Mrs. Sanchez’s claim because it
determined that Mr. Sanchez’s death was not the result of a “Covered Accident”:
“[a] sudden, unforeseeable, external event that results, directly and independent
of all other causes, in a Covered Injury or a Covered Loss.” This circuit reviews
plan administrators’ coverage decisions de novo unless the plan expressly gives
discretionary authority over these decisions to the plan administrator. Stone v.
UNOCAL Termination Allowance Plan, 570 F.3d 252, 257 (5th Cir. 2009).
Where discretion has been granted, we review coverage decisions only for abuse
of discretion. Id. We apply the later review here because LINA possesses “the
authority, in its discretion, to interpret the terms of the plan documents and
decide questions of eligibility for coverage or benefits under the plan and to
make any related findings of fact.” A plan administrator’s factual
determinations are always reviewed for abuse of discretion. Stone, 570 F.3d at
257.
To determine whether a plan administrator has abused its discretion, the
court applies a two-step analysis. Crowell v. Shell Oil Co., 541 F.3d 295, 312
(5th Cir. 2008). The first step is to determine whether the administrator’s
decision was “legally correct.” Id. (citing Pickrom v. Belger Cartage Serv., Inc.,
57 F.3d 468, 471 (5th Cir. 1995)). If it was, our inquiry ends, as a legally correct
decision precludes any abuse of discretion. Id. If the administrator’s
interpretation was not legally correct, we review it for abuse of discretion. Stone,
570 F.3d at 257. In cases where “we can more readily determine that the
decision was not an abuse of discretion,” we may proceed directly to the second
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prong of the analysis. Holland v. Int’l Paper Co. Ret. Plan, 576 F.3d 240, 246 n.2
(5th Cir. 2009) (collecting cases). We will follow this method of analysis and
proceed immediately to the second prong.
An abuse of discretion occurs when a plan administrator’s decision is not
“based on evidence, even if disputable, that clearly supports the basis for its
denial.” Id. at 246 (quotation marks and citations omitted). This review is
“synonymous with arbitrary and capricious review.” Cooper, 592 F.3d at 652.
A decision is arbitrary if it is “made without a rational connection between the
known facts and the decision or between the found facts and the evidence.”
Meditrust Fin. Servs. Corp. v. Sterling CheMrs., Inc., 168 F.3d 211, 215 (5th Cir.
1999) (quotation marks and citation omitted). “[R]eview of the administrator’s
decision need not be particularly complex or technical; it need only assure that
the administrator’s decision fall[s] somewhere on a continuum of
reasonableness¯even if on the low end.” Corry v. Liberty Life Assurance Co. of
Boston, 499 F.3d 389, 398 (5th Cir. 2007) (quotation marks and citation omitted).
As part of the abuse of discretion prong of the analysis, we must also
consider any conflicts of interest. Holland, 576 F.3d at 247. “[W]e weigh the
conflict of interest as a factor in determining whether there is an abuse of
discretion in the benefits denial, meaning we take account of several different
considerations of which conflict of interest is one.” Id. (citing Crowell, 541 F.3d
at 312 ). See also Metro. Life Ins. Co. v. Glenn, 554 U.S. 104, __, 128 S. Ct. 2343,
2350S51 (2008). Here, a conflict exists because LINA was responsible for both
determining eligibility and paying benefits. See, e.g., Glenn, 554 U.S. at __, 128
S. Ct. at 2350. This type of conflict, however, is a “minimal” one. Corry, 499
F.3d at 398. Mrs. Sanchez has not put forth any evidence or argument regarding
any other conflicts.
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First, we first address whether LINA’s factual determination that Mr.
Sanchez’s impaired driving caused his fatal crash was an abuse of discretion.
There is ample evidence in the record¯including his reported blood alcohol level
of 0.174%¯that Mr. Sanchez was driving under the influence of alcohol and no
evidence pointing to an alternate explanation for the crash. Both parties’
experts agreed that individuals with a blood alcohol level of 0.174% “are at
greater risk of having an accident due to impairment of driving-related skills
such as reaction time.” Evidence also exists that Mr. Sanchez did not appear to
be impaired when he chose to drive home, that he drove twenty-three miles
without any documented problem, and that persons under the influence of
alcohol often drive without incident. Considering this evidence and LINA’s
“minimal” conflict of interest, we find that LINA did not abuse its discretion
when it determined that driving under the influence of alcohol contributed to
Mr. Sanchez’s automobile crash. This decision is supported by evidence on the
record and “fall[s] somewhere on a continuum of reasonableness.” Corry, 499
F.3d at 398 (quotation marks and citation omitted).
We next evaluate whether LINA abused its discretion by interpreting the
Policy’s definition of a “Covered Accident”¯“[a] sudden, unforeseeable, external
event”¯not to include the single-car crash caused by Mr. Sanchez’s driving under
the influence of alcohol. In addition to the evidence noted above, the record also
shows the following: (1) Mr. Sanchez’s blood alcohol level of 0.174% was more
than twice the legal limit for driving an automobile in Texas; (2) the medical
examiner concluded that Mr. Sanchez’s death was the result of multiple injuries
and was an “accident”; (3) five witnesses reported that Mr. Sanchez’s vehicle
swerved sharply in the road and rolled over several times before ejecting him;
(4) Mrs. Sanchez made an (unsupported) claim that most people who drive drunk
are not involved in deadly accidents, making there “not a high likelihood Mr.
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Sanchez would be involved in an accident and die”; (5) Dr. Fochtman opined that
a person with Mr. Sanchez’s blood alcohol level would have “poor judgment,
increased reaction time, muscle incoordination, loss of visual acuity, [] increased
risk taking” and be unable to drive safely; (6) Dr. Garriott submitted that “[t]he
degree to which individuals are affected by alcohol is largely a function of
tolerance” and “Mr. Sanchez had a considerable alcohol tolerance”; and (7) Dr.
Fochtman cited “volumes of references regarding the effects of alcohol producing
impairment regardless of tolerance.”
Based on all of the evidence in the record, and again considering LINA’s
minimal conflict of interest, we conclude that LINA did not abuse its discretion
when it determined that Mr. Sanchez’s death was not the result of “[a] sudden,
unforeseeable, [and] external event.” Additional evidence regarding the
foreseeability of a fatal crash resulting from driving under the influence would
have strengthened LINA’s decision.3 Its denial of coverage is nevertheless
“based on evidence, even if disputable, that clearly supports the basis for its
denial.” Holland, 576 F.3d at 246 (quotation marks and citations omitted).
LINA’s conclusion “fall[s] somewhere on a continuum of reasonableness¯even
if on the low end.” Corry, 499 F.3d at 398 (quotation marks and citation
omitted). It was therefore not an abuse of discretion.
Our resolution of this appeal is consistent with Davis v. Life Insurance Co.
of North America, 2010 WL 2102040 (5th Cir. May 26, 2010) (per curiam),4 which
presents nearly identical facts. Davis, whose blood alcohol level was between
3
The weight of the evidence presented by both parties relates to the factual question
of whether or not Mr. Sanchez’s driving under the influence caused the crash. A lesser amount
of evidence was presented on the issue of whether or not a crash in these circumstances was
an “unforeseeable” event.
4
Mrs. Sanchez included a now-moot request in her reply brief that oral argument in
her appeal be combined with that in Davis.
8
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0.28% and 0.368%, died when the motorcycle he was driving left the road. Id.
at *1. No other persons or vehicles were involved in the crash and no weather,
vehicle, or road conditions that may have contributed to the crash were noted,
although witnesses testified that Davis did not appear intoxicated. Id. LINA
denied coverage on Davis’s policy for the same reasons cited in this case: there
was no “Covered Accident” and coverage was precluded by the self-inflicted
injury exclusion. Id. Finding that “[t]he policy does not define the term
‘unforeseeable,’” and that LINA interpreted that term “in a manner consistent
with the term’s plain meaning,” we affirmed a grant of summary judgment to
LINA. Id. at *3 (citation omitted).
LINA also denied Mrs. Sanchez’s claim because it determined that Mr.
Sanchez’s death fell under the “intentionally self-inflicted Injury” exclusion in
the Policy. Because our decision on LINA’s interpretation of a “Covered
Accident” is determinative of coverage, we need not address this issue. See id.CONCLUSION
For the reasons set forth above, we AFFIRM the district court’s entry of
judgment in favor of LINA.
9