Brown v. PFL Life Insurance

United States Court of Appeals
Fifth Circuit
F I L E D
IN THE UNITED STATES COURT OF APPEALS
October 1, 2004
FOR THE FIFTH CIRCUIT
Charles R. Fulbruge III
____________________ Clerk
No. 04-60208
Summary Calendar
____________________
DAWN BROWN
Plaintiff - Appellant
v.
PFL LIFE INSURANCE CO
Defendant - Appellee
_________________________________________________________________
Appeal from the United States District Court
for the Northern District of Mississippi, Aberdeen
No. 1:02-CV-212
_________________________________________________________________
Before KING, Chief Judge, and HIGGINBOTHAM and PRADO, Circuit
Judges.
PER CURIAM:*
Plaintiff-Appellant, Dawn Brown (“Brown”), is the designated
beneficiary of an accidental death insurance policy under which
her father, Terry Gilmer (“Gilmer”), was the insured. The plan
*
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that this opinion should not be published and is not precedent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.
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administrator concluded that Gilmer did not die as a result of an
accident as defined in the policy and thus, denied Brown’s claim
for benefits under the policy. Brown appeals the district
court’s holding that the plan administrator did not abuse its
discretion in denying her the benefits. For the following
reasons, we AFFIRM the judgment of the district court.
I. Background
Gilmer was an employee of Nolen Sistrunk, Inc. (“Sistrunk”),
a Mississippi trucking company. At the beginning of his
employment, Gilmer accepted an accidental death insurance policy
offered by Sistrunk. PFL Life Insurance Company (“PFL”)
administered and financed the policy. Gilmer designated his
daughter, Brown, as the policy’s beneficiary. She would receive
$1,000 per month, for life, guaranteed for twenty years, upon
proof that the insured’s death resulted directly from an
accident.
On June 22, 1999, Gilmer died following a traffic accident.
The accident occurred while he was driving his employer’s truck
east on Interstate 20 in Louisiana. According to witnesses,
Gilmer’s truck swerved and crashed into the back of another
truck. The police report stated that at the time of the accident
the road conditions were good, the weather was clear, and there
were no visual obscurities. In addition, the truck Gilmer was
driving, as well as the other truck, had no known defects.
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Brown timely submitted a claim to PFL under the accidental
death insurance policy. PFL denied Brown’s claim after an
investigation in which it concluded that Gilmer’s death did not
fall within the terms of the policy. PFL found that Gilmer
suffered a cardiac event while he was driving and that caused the
collision. PFL therefore concluded that Gilmer’s heart attack
contributed to his death and thus, that his death was not the
result of an accident as defined in the policy.
Brown subsequently brought an action against PFL asserting a
claim for bad faith denial of benefits in the Circuit Court of
Attala County, Mississippi. PFL removed the case to the United
States District Court for the Northern District of Mississippi.
After a non-jury trial, the district court entered judgment for
PFL holding that PFL’s decision to deny the accidental death
benefits was not an abuse of discretion because, inter alia, its
decision was neither arbitrary nor capricious.
II. Discussion
A. Standard of Review
The Employee Retirement Income Security Act provides the
district courts with the authority to review a plan
administrator’s denial of plan benefits. 29 U.S.C.
§ 1132(a)(1)(B) (2004). The district court reviews a plan
administrator’s factual determinations for an abuse of discretion
when it has denied benefits under a plan. Vercher v. Alexander &
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Alexander, Inc., 379 F.3d 222, 226 (5th Cir. 2004) (citing
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989));
Pierre v. Connecticut Gen. Life Ins., 932 F.2d 1552 (5th Cir.
1991), cert. denied, 502 U.S. 973 (1991)). In applying the abuse
of discretion standard, the district court analyzes whether the
plan administrator acted arbitrarily or capriciously. Bellaire
Gen. Hosp. v. Blue Cross Blue Shield of Mich., 97 F.3d 822, 829
(5th Cir. 1996). A plan administrator’s decision is deemed
arbitrary if it is made “without a rational connection between
the known facts and the decision or between the found facts and
the evidence.” Lain v. Unum Life Ins. of Am., 279 F.3d 337, 342
(5th Cir. 2002) (quoting Bellaire Gen. Hosp., 97 F.3d at 828).
An administrator’s decision must be based on evidence, even if
disputable, that clearly supports the basis for denial, and there
must be some concrete evidence in the record to support the plan
administrator’s decision. Vega v. Nat’l Life Ins. Servs., Inc.,
188 F.3d 287, 299 (5th Cir. 1999). The district court, in
reviewing the plan administrator’s decision, can only consider
the evidence that was before the plan administrator. Id.We in turn review de novo the district court’s legal
conclusion that the plan administrator abused its discretion.
Hammack v. Baroid Corp., 142 F.3d 266, 270 (5th Cir. 1998)
(citing Sunbeam-Oster Co. Group Benefits Plan v. Whitehurst, 102
F.3d 1368, 1373 (5th Cir. 1996)).
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B. Analysis
We first examine the terms of the accidental death insurance
policy. The relevant terms of the policy provide that the
benefits would be payable upon proof that the “insured’s death
resulted directly from accidental bodily injury and independently
of disease or bodily infirmity or any other cause.” The terms of
the policy further provide that the benefits would not “be
payable if death results, directly or indirectly . . . or is
contributed to, wholly or in part, by . . . disease or medical or
surgical treatment of disease . . . .”
We now turn to the relevant evidence before PFL, which
consisted of Gilmer’s death certificate, an autopsy report, the
statements of the doctor who performed the autopsy, Gilmer’s
medical records, the police report, and the investigating
officer’s statements. The death certificate provided that acute
and ongoing myocardial infarction, i.e, a heart attack, was a
significant cause of Gilmer’s death. The autopsy report provided
that Gilmer’s death “was due to multiple traumatic injuries” and
that “[t]here was no evidence of recent abuse of ethanol or other
common drugs.” The autopsy report also stated that Gilmer “had
ongoing myocardial infarction, with recent thrombosis of the left
coronary artery” that “may have caused the accident.” Upon
questioning, the doctor who performed the autopsy, Dr. Young,
stated that Gilmer was having a heart attack for some time. Dr.
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Young, however, maintained only that the heart attack “may have
caused” the accident.
Gilmer’s medical records revealed that he suffered from high
blood pressure, which was poorly controlled, complained of
shortness of breath and dizziness, and was a smoker. Moreover,
as previously discussed, the police report indicated that the
weather and road conditions were good when Gilmer’s truck swerved
and hit the other truck. Further, the accident investigator,
after referring to the autopsy report, attributed the accident to
the fact that Gilmer was suffering a cardiac event, or, less
likely, fell asleep at the wheel.
Brown’s argues on appeal that PFL could deny the benefits
only if the heart attack was the probable cause of Gilmer’s
death. This argument is unavailing. Under the abuse of the
discretion standard, PFL’s decision need only evince a “rational
connection between the known facts and the decision.” Lain, 279
F.3d at 342 (quoting Bellaire Gen. Hosp., 97 F.3d at 828).
Considering all the evidence before PFL, it could have rationally
concluded that Gilmer’s heart attack contributed to his death.
Specifically, the undisputed evidence shows that Gilmer’s health
was poor, that he was having a heart attack while he was driving,
that nothing about the road conditions or the weather could be
said to have contributed to the accident, and that in the opinion
of two experienced professionals--Dr. Young and the investigator-
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-the heart attack may have caused the accident. A rational
conclusion from this evidence is that Gilmer was suffering a
heart attack that impaired his ability to drive and caused him to
swerve into the other truck. As such, PFL’s conclusion was not
arbitrary or capricious, and PFL had a sound basis for denying
Brown’s claim for benefits under the terms of the policy.
III. Conclusion
For the foregoing reasons, we agree with the district court
that PFL did not abuse its discretion when it denied Brown the
benefits under the accidental death insurance policy. We
therefore AFFIRM the judgment of the district court.