Tamica Shaw v. The Prudential Ins. Co.

Filing

PER CURIAM OPINION FILED - THE COURT: Duane Benton, C. Arlen Beam and Bobby E. Shepherd (UNPUBLISHED) [4160337] [13-1210]

United States Court of Appeals
For the Eighth Circuit
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No. 13-1210
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Tamica Shaw
lllllllllllllllllllll Plaintiff - Appellant
v.
The Prudential Insurance Company of America
lllllllllllllllllllll Defendant - Appellee
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Appeal from United States District Court
for the Western District of Missouri - Springfield
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Submitted: November 19, 2013
Filed: June 3, 3014
[Unpublished]
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Before BENTON, BEAM, and SHEPHERD, Circuit Judges.
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PER CURIAM.

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In this Employee Retirement Income Security Act ("ERISA") case, Tamica
Shaw appeals from the district court's1 grant of summary judgment in favor of The
Prudential Insurance Company of America ("Prudential"). We affirm.
I.

BACKGROUND

On March 4, 2006, Tamica's husband, Carl Shaw, was killed in a single-vehicle
accident in Springfield, Missouri. According to an investigative report, Carl's vehicle
went airborne after he crossed over railroad tracks at a high rate of speed, eventually
causing him to careen into a building. A subsequent toxicology report revealed that
Carl had a blood alcohol level of 0.126% at the time of his death.
Tamica filed a claim with Prudential seeking benefits from an accidental death
and dismemberment policy ("AD&D") she had purchased from Prudential through
her employer, JPMorgan Chase Bank, N.A. ("Chase"), as part of a group insurance
contract. The AD&D policy excluded coverage if a loss resulted from "[a]n accident
that occurs while operating a motor vehicle involving the illegal use of alcohol."
Based on this exclusion, on June 21, 2006, Prudential denied the claim, indicating
that, at the time of his death, Carl had a blood alcohol level exceeding the limit
allowed to operate a motor vehicle in Missouri. Tamica appealed the decision in two
separate letters to Prudential dated October 2, 2006, and February 7, 2007, arguing
that neither the police report nor the certificate of death cited alcohol as a contributing
factor in Carl's death.
On March 12, 2007, Prudential upheld its decision to disallow the claim, again
relying on the alcohol exclusion. On May 10, 2007, after receiving and reviewing
additional records, Prudential revised its denial letter, this time citing a felony

1

The Honorable David Gregory Kays, United States District Judge for the
Western District of Missouri.
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exclusion in addition to maintaining denial based on the alcohol exclusion. On July
30, 2007, Tamica appealed from this decision. In her appeal letter, Tamica indicated
that her letter "serv[ed] as an appeal to Prudential's Appeal Review Committee for
a final decision relative to Prudential's May 10, 2007, letter denying the payment of
life insurance proceeds." On September 28, 2007, Prudential issued its final decision
denying the claim. Nearly two years after this denial, Tamica obtained new counsel
and pressed Prudential for additional review.
On July 27, 2010, Tamica commenced action in Missouri state court, alleging
Prudential breached the AD&D policy. Prudential removed the case to federal court
and Tamica sought a remand. Finding that Tamica had alleged ERISA claims, the
district court denied remand. Tamica then amended her complaint to include one
state law claim and, in the alternative, an ERISA claim. Prudential moved for partial
summary judgment on the state law claim. Again, finding that ERISA governed the
dispute, the district court granted partial summary judgment in favor of Prudential,
dismissing Tamica's Missouri state law claim. Subsequently, the parties filed crossmotions for summary judgment on the remaining ERISA claim. Reviewing
Prudential's decision for an abuse of discretion, the district court determined that
Prudential's decision was reasonable and supported by substantial evidence and, thus,
granted Prudential's motion. Tamica now appeals.
II.

DISCUSSION
A.

Standard of Review

Tamica challenges the district court's determination that an abuse of discretion
standard applied to Prudential's decision. We review the district court's grant of
summary judgment de novo, as well as its determination that Prudential's decision is
governed by an abuse of discretion standard. Sahulka v. Lucent Techs., Inc., 206
F.3d 763, 767 (8th Cir. 2000).
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Generally, when an ERISA plan grants the administrator discretionary authority
to "make eligibility determinations, the administrator's decision is reviewed for an
abuse of discretion." Trs. of Electricians' Salary Deferral Plan v. Wright, 688 F.3d
922, 926 (8th Cir. 2012) (quotation omitted). However, if the ERISA plan fails to
grant such authority, we review the administrator's decision de novo. Nichols v.
Unicare Life and Health Ins. Co., 739 F.3d 1176, 1181 (8th Cir. 2014).
Tamica asserts three reasons why a de novo standard applied in this case: (1)
the specific AD&D policy failed to provide discretionary authority to the Plan
administrator; (2) the summary plan description (SPD) and other documents granting
discretionary authority are not part of the AD&D policy; and (3) Prudential did not
properly amend the AD&D policy to include discretionary authority. We find these
related contentions unpersuasive under present circumstances.
Our cases establish a few principles to discern the appropriate standard of
review in the type of situation we now confront. We have recognized that "a grant
of discretion to the plan administrator, appearing only in a [SPD], does not vest the
administrator with discretion where the policy provides a mechanism for amendment
and disclaims the power of the summary plan description to alter the plan." Ringwald
v. Prudential Ins. Co. of Am., 609 F.3d 946, 948 (8th Cir. 2010) (quotation omitted).
Yet, at the same time, we have never held that the discretion-granting language must
appear only in the individual welfare policy or SPD to have effect.2 See McKeehan
v. Cigna Life Ins. Co., 344 F.3d 789, 793 (8th Cir. 2003) ("[W]e require explicit
discretion-granting language in the policy or in other plan documents to trigger the
ERISA deferential standard of review.") (emphasis added) (internal quotation
omitted)); Rittenhouse v. UnitedHealth Grp. Long Term Disability Ins. Plan, 476 F.3d
626, 629 (8th Cir. 2007) ("The triggering language may appear in a plan document

2

On this point, we fundamentally disagree with Tamica's reading of Jobe v.
Medical Life Ins. Co., 598 F.3d 478 (8th Cir. 2010), and Ringwald.
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other than the SPD."). Indeed, "an ERISA plan must be inferred from a series of
documents," Administrative Committee of Wal-Mart Stores, Inc. v. Gamboa, 479
F.3d 538, 542 (8th Cir. 2007), and in interpreting the terms of the plan, like all
contracts, "[c]ourts must look at the ERISA plan as a whole," Johnson v. American
United Life Insurance Co., 716 F.3d 813, 820 (4th Cir. 2013). To this end, although
in a slightly different context, in Gamboa, we acknowledged the controlling effect of
"wrap-plan" documents that "provide[] the governing structure of the overall Plan and
describe[] the general procedures for determining participation, funding,
administration, and claims under each individual welfare program." 479 F.3d at 542.
Presently, although the individual AD&D policy at issue does not contain
discretion-granting language, other Plan documents unambiguously grant such
authority. In addition to the individual welfare policies, Tamica's ERISA Plan
contains a global document entitled "Health and Income Protection Program for
JPMorgan Chase Bank and Certain Affiliated Companies." This wrap-plan
document, like in Gamboa, "provides the governing structure of the overall Plan and
describes the general procedures for determining participation, funding,
administration, and claims under each individual welfare program." Id. Furthermore,
the wrap-plan document informs the employee that the ERISA Plan is evidenced by
the wrap-plan document itself, as well as the SPDs and the individual insurance
policies, among other named documents. Section 4.2 of this document declares that
"[b]enefits under the Program or a Plan[3] will be paid only if the Program
Administrator or its delegates decides in its discretion that a Participant is entitled to
them." Given that this Plan document provides such a clear and explicit grant of
3

The wrap document defines "Plan" as "any one of the employee benefit plans
. . . which is maintained for the benefit of Eligible Employees and their Dependants."
"Program" is defined as the "Health and Income Protection Program for JPMorgan
Chase Bank and Certain Affiliated Companies," and "references . . . to the Program
shall include each individual Plan." Unlike Tamica, given these definitions, we find
it insignificant that the wrap document is entitled "Program" instead of "Plan."
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discretion, we find it unnecessary to address Tamica's arguments concerning whether
the discretion-granting language in the SPDs–incorporated by reference into the
wrap-plan document–has any controlling effect. The district court did not err in
determining an abuse of discretion standard applied.
B.

The Administrative Record

Tamica takes issue with materials the district court refused to consider as part
of the administrative record. Specifically, because the district court was reviewing
Prudential's final decision dated September 28, 2007, the court refused to consider
any materials Tamica submitted to Prudential after that date. Tamica argues that she
submitted evidence to Prudential after September 28, 2007, including a request for
reconsideration; that Prudential considered the evidence in responding to her request
for reconsideration before she filed suit; that Prudential submitted these additional
materials to the district court as part of the certified record; and that Prudential cited
some of these materials in its motion for summary judgment. Thus, in Tamica's view,
the district court erred in refusing to consider evidence submitted to Prudential after
September 28, 2007.
In reviewing a plan administrator's denial of benefits, courts "consider only the
evidence that was before the administrator when the claim was denied." Sahulka, 206
F.3d at 769. In Rittenhouse, we rejected arguments similar to those Tamica now
asserts. 476 F.3d at 630-31. There, much like the present case, after the plan
administrator issued its final decision, the employee pressed the administrator to
reconsider its position and submitted additional evidence. Id. at 630. We concluded
the district court abused its discretion in considering the employee's additional
evidence submitted to the plan administrator, as the employee offered no explanation
why the relevant evidence could not have been submitted before a final administrative
decision was rendered. Id. at 631.

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We find Rittenhouse controls here and any slight distinctions are without a
difference. Tamica has offered no explanation as to why she could not submit all her
evidence during the administrative appeals process and waited nearly two years after
Prudential issued its final decision to finally submit the evidence to Prudential.
Tamica is not entitled to limitless review merely because she decided to switch
counsel after her final administrative appeal had been denied. See Davidson v.
Prudential Ins. Co. of Am., 953 F.2d 1093, 1096 (8th Cir. 1992) ("[T]he
administrative [review] process must end at some point." (second alteration in
original) (quotation omitted)). Therefore, the district court did not abuse its
discretion in refusing to consider evidence that Tamica failed to timely submit during
the administrative appeals process.
C.

Conflict of Interest and Procedural Irregularities

Even if the plan documents vest Prudential with discretion, Tamica suggests
that the district court failed to consider Prudential's conflict of interest. See Khoury
v. Grp. Health Plan, Inc., 615 F.3d 946, 953 (8th Cir. 2010) ("The existence of a
conflict of interest is one factor among many that a reviewing judge must take into
account when determining whether a plan administrator has abused its discretion in
denying benefits." (internal quotation omitted)). The record belies Tamica's
contention. In its order denying her motion for reconsideration, the district court
noted that it had considered the conflict of interest but concluded that any potential
conflict "did not influence or otherwise override the other factors Prudential
considered in denying Plaintiff benefits." We agree with the district court's
assessment.
Tamica also complains that Prudential abused its discretion by failing to
engage in a full and fair review of her claim because its claim handling process was
riddled with procedural irregularities. Several of Tamica's perceived procedural

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irregularities seem to stem from her mischaracterization of the record and outright
misstatements of law. For example, in one of her many assertions, Tamica claims that
"Prudential did not give [Tamica's] contentions fair consideration, and failed to give
specific reasons for denying the claim and for not considering critical evidence." A
review of the record reveals a different story. In each of its claim denial letters,
Prudential gave specific reasons for the denial, cited evidence, and responded to each
of Tamica's arguments. In its final decision, Prudential noted that Tamica appealed
but failed to provide any additional information for Prudential to review. After
thoroughly reviewing the record, we see no abuse of discretion based on procedural
irregularities.
D.

Alcohol Exclusion

As to the merits of the underlying denial, Tamica argues that the district court
erred in concluding the alcohol exclusion precluded coverage under the AD&D
policy. Because we have determined that an abuse of discretion standard applies, the
"administrator's decision to deny benefits will stand if a reasonable person could have
reached a similar decision." Ratliff v. Jefferson Pilot Fin. Ins. Co., 489 F.3d 343, 346
(8th Cir. 2007) (quotation omitted). A decision is not unreasonable merely because
the plan is susceptible to differing interpretations. River v. Edward D. Jones Co., 646
F.3d 1029, 1032 (8th Cir. 2011). "Rather, a court will reverse a claims administrator's
determination only if it is arbitrary and capricious." Id. Accordingly, where a plan
administrator offers a reasonable explanation for a decision that is supported by
substantial evidence–such evidence that a reasonable mind might find adequate to
support the conclusion–we will not disturb the decision. Id. at 1033.
Recall, the alcohol exclusion provides that "[a] loss is not covered if it results
from . . . [a]n accident that occurs while operating a motor vehicle involving the
illegal use of alcohol." Tamica finds several aspects of this provision ambiguous,

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namely, the "results from" language, the "illegal use of alcohol" language, and the
lack of a named vehicle operator. After reviewing the record and our precedent, we
conclude that the plan administrator offered a reasonable interpretation and
application of the exclusion to the facts of this case. See id. at 1033 ("We conclude
that, based on [the intoxication] exclusion alone, [the plan administrator] did not
abuse its discretion as plan administrator when it denied benefits.").
E.

Substantial Evidence

Tamica also asserts that Prudential's decision is not supported by substantial
evidence because "the great weight of the evidence in the record . . . establishes the
blood test results are not reliable and that Carl Shaw did not drink alcohol on the
night he died." We rejected similar assertions in River. There, we determined that
the plan administrator acted reasonably by relying on a "certified toxicology report
issued by the Missouri State Highway Patrol Crime Laboratory Division and signed
by one of its technicians," which showed the decedent had a blood alcohol level of
0.128%, notwithstanding evidence indicating the decedent was not intoxicated. Id.
at 1033 & n.2. Here, the Missouri State Highway Patrol Crime Laboratory Division
issued a report indicating Carl's blood alcohol level was 0.126% at the time of the
accident. This toxicology report satisfies the substantial evidence standard even if
contrary evidence existed. Id. at 1034.
F.

Toxicology Report

Finally, Tamica challenges the reliability and evidentiary value of the
toxicology report because proper procedure was not followed in drawing and testing
Carl's blood. After thoroughly reviewing the record, we are satisfied that Prudential
acted reasonably in relying on the toxicology report.

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III.

CONCLUSION
We affirm the judgment of the district court.
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