Giacomini, Stephanie v. Standard Insurance Company
Filing
33
ORDER granting 15 Motion for Summary Judgment. Signed by District Judge William M. Conley on 9/15/2015. (jls)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
STEPHANIE GIACOMINI,
Plaintiff,
v.
OPINION & ORDER
14-cv-533-wmc
STANDARD INSURANCE COMPANY,
Defendant.
Pursuant to 29 U.S.C. § 1132(a)(1)(B), plaintiff Stephanie Giacomini seeks to
recover accidental death and dismemberment (“AD&D”) benefits she contends are due
her under an employee welfare benefit plan governed by the Employee Retirement
Income Security Act of 1974 (“ERISA”). The plan consists of a group life and accidental
death and dismemberment policy issued and underwritten by defendant Standard
Insurance Company.
Pending before the court is defendant’s motion for summary
judgment. (Dkt. #15.) Under the applicable arbitrary and capricious standard, the court
now finds defendant is entitled to judgment as a matter of law for reasons explained
below. 1
This court has jurisdiction over this case pursuant to 29 U.S.C. § 1132(e)(1) and 28 U.S.C. §
1331.
1
UNDISPUTED FACTS 2
I. Background
The employee welfare benefit plan at issue is sponsored by Cargill, Inc., who
employed plaintiff’s husband, Karl Giacomini. In turn, that plan was insured under a
group life insurance policy, Policy No. 647267-A (“the Policy”), which was issued by
defendant Standard Insurance Company (“Standard”). The Policy contains an express
“Allocation of Authority” provision granting discretionary authority to Standard in
interpreting the Policy and administering claims.
In terms of benefits for plan members, the Policy provides basic life insurance
coverage, additional life insurance coverage and AD&D coverage. With respect to the
last, the Policy provides: “If you or your Spouse have an accident, including accidental
exposure to adverse conditions, while insured for AD&D Insurance, and the accident
results in a Loss, we will pay benefits according to the terms of the Group Policy after we
receive Proof of Loss satisfactory to us.” “Loss” is defined as “loss of life . . . which meets
all of the following requirements:
1. Is caused solely and directly by an accident.
2. Occurs independently of all other causes.
3. With respect to Loss of life, is evidenced by a certified copy of the death
certificate.”
While plaintiff interposes numerous hearsay objections to Standard’s proposed findings of fact,
“[t]he [c]ourt is not bound by the Federal Rules of Evidence when reviewing an ERISA
administrator’s benefits determination.” Rice v. ADP TotalSource, Inc., 936 F. Supp. 2d 951, 961
(N.D. Ill. 2013) (citing Black v. Long Term Disability Ins., 582 F.3d 738, 746 n.3 (7th Cir. 2009)).
Accordingly, the court “review[s] the entire administrative record, including hearsay evidence
relied upon by the administrator.” Black, 582 F.3d at 746 n.3.
2
2
(Administrative Record (dkt. #18-1) 138 [hereinafter “AR”].)
The Policy also provides, however, that “[n]o AD&D Insurance benefit is payable
if the accident or Loss is caused or contributed to by any of the following . . . 4. The
voluntary use or consumption of any poison, chemical compound, or drug, unless used or
consumed according to the directions of a Physician, or legal intoxication while operating
a motor vehicle.” (Id. at 139.)
II. Plaintiff’s Claim for Benefits
On July 22, 2013, Standard received a Life Insurance Benefits Proof of Death
Claim Form stating that Karl Giacomini died two days earlier, and that his beneficiary
was his spouse, Stephanie. The form claimed $146,000 in basic life insurance benefits;
$365,000 in additional life insurance benefits; and $500,000 in AD&D insurance
benefits.
In describing how Karl Giacomini’s injury occurred, his certified death
certificate stated: “Unhelmeted driver of ATV that was thrown to ground after losing
control of ATV.” The certificate also listed “Subdural Hemorrhage” and “Subarachnoid
Hemorrhage” as the “IMMEDIATE CAUSE” of death, and “BAC .187” under the
heading of “OTHER SIGNIFICANT CONDITIONS contributing to death but not
resulting in the underlying cause given in Part I.” (AR (dkt. #18-3) 389.)
By letter dated August 7, 2013, Standard paid Stephanie Giacomini $511,000 in
basic and additional life insurance benefits, while noting that the claim for AD&D
benefits was under review. (Id. at 388.)
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III. Standard’s Investigation
Standard considered numerous, additional records in connection with its review of
the AD&D benefits claim. Among the records is an Officer Incident Report prepared by
the Wisconsin Department of Natural Resources Bureau of Law Enforcement, which
states that on Saturday, July 20, at 1:05 a.m., a one-vehicle crash occurred involving an
ATV on a public road in Ellington, Wisconsin. (AR (dkt. #18-3) 350-53.) That report
classifies the type of incident as a fall “from moving snowmobile/ATV/UTV.” (Id.) It
also states that the weather was “Clear,” the visibility was “Good,” the temperature was
sixty-six degrees Fahrenheit and the road condition was “Dry.” (Id.)
The same Officer Incident Report states as follows:
Sometime between [9:30 and 10 p.m.] and the accident, the
victim drove his ATV further north down Greenwood Road
to meet individuals in the neighborhood at a party.
Witnesses said the victim had been drinking alcoholic
beverages while at the party. Just prior to 1:00 am, the victim
left the party and began driving home on the paved portion
of Greenwood Road. A resident at N3423 Greenwood Road
heard screeching and what sounded like a vehicle crashing at
approximately 1:05 am. The individual came outside and
found the victim lying on the east edge of the pavement and
observed the ATV lying on [its] side in the east ditch. This
individual called 911.
. . . Based on the marks on the pavement, total distance of
travel, and damage to the ATV, speed is believed to be a
factor. It was observed that there were five unopened cans of
the alcoholic beverage Lime-A-Rita lying scattered around the
ATV as well as the cardboard 12 pack container they had
been contained in. Based on this observation and witness
statements, alcohol is also believed to have been a factor.
4
(Id.)
Consistent with that narrative, the report classifies Karl Giacomini’s operator
condition as “Had Been Drinking” and records his blood alcohol content (“BAC”) as .18.
(Id. at 351.)
The record also contains a Case Activity Report prepared by the Wisconsin
Department of Natural Resources Bureau of Law Enforcement, which states that: Karl
Giacomini was found unconscious; the ATV was not carrying passengers; and deputies
from the Outagamie County Sheriff’s Department interviewed individuals who had
observed Karl Giacomini drinking alcohol and operating the ATV before the accident
occurred. (Id. at 354.) The report further stated:
Information was obtained through interviews, by the
Outagamie Sheriff’s Department, that Giacomini was at a
neighborhood party just north of the accident on Greenwood
Road. Witnesses said that Giacomini was drinking alcoholic
beverages while at the party.
Giacomini left the
neighborhood party at approximately 1:00 AM to go back to
his home located at N3405 Greenwood Road. Giacomini
drove his ATV southbound on Greenwood Road on the paved
surface. At approximately 1:00 AM, a resident at Redacted,
later identified as Ricky A. Much, heard an ATV go by his
house, heard a strange noise, and did not hear the ATV again.
Much went outside and saw the ATV tipped over in the ditch
and Giacomini lying on the eastside of Greenwood Road. . . .
(Id. at 355.)
Like the Officer Incident Report, the Case Activity Report notes that
Bureau wardens observed “a twelve pack cardboard case of Bud Light Lime-A-Rita beer
with five unopened cans” at the scene. (Id.) Medical records indicate no one saw the
accident itself.
A supplemental report prepared by Sergeant Jacob Pasch, an officer of the
Outagamie County Sheriff’s Department, discusses an interview with the host of the
5
party, Michael W. Greil. (Id. at 370.) According to Greil, Karl Giacomini had driven his
ATV to the party, at which everyone was “consuming alcohol.” (Id.) An additional
supplement prepared by Sergeant Travis Linskens states that Ricky Much, who had also
attended the party, confirmed that Karl Giacomini “had been drinking.” (Id. at 369.)
Sgt. Linskens also “observed yaw marks that appeared to be from the ATV” and the five
unopened cans of Lime-A-Rita at the scene. (Id. at 368.) A final supplement by Deputy
James Schaut corroborates the presence of the five full beer cans at the scene. (Id. at
367.)
Records from Theda Clark Medical Center indicate that a helicopter transported
Karl Giacomini to the center and that he arrived at 1:57 a.m. on July 20, 2013. (Id. at
336-37.) Those records also indicate that Karl Giacomini’s blood was drawn at 2:10 a.m.
and that lab results revealed a BAC of 187 mg/dl. (Id. (dkt. #18-2) 268.) Doctor Steven
Weinshel later ordered a nuclear medicine brain flow scan, which showed no evidence of
intercranial blood flow. (Id. at 304.) At 11:00 a.m. that same morning, Dr. Weinshel
declared Karl Giacomini brain dead. (Id.)
A Modified Hospital Admission Coroner’s Report prepared by the Outagamie
County Office of the Coroner states that Giacomini had a “[s]ubdural hematoma isolated
head” injury. The Coroner described the “Terminal Event” as follows: “Patient fell from
a moving ATV. He was not wearing a helmet. Sustained isolated head trauma. He had
a glas[g]ow coma scor[e] of 3 on scene. The patient fell due to speed and alcohol.” (Id.at
161.)
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Beyond this record review, Standard also consulted with Steven C. Beeson, M.D.,
who was Board Certified in Internal Medicine. In his Physician Consultant Memo, dated
October 2, 2013, Dr. Beeson responded to one of Standard’s questions as follows:
1. How would a blood alcohol content of 0.187 affect a person’s
ability to operate a motor vehicle?
Patients with that level of alcohol intoxication have
significant gross motor impairment, lack of physical control,
blurred vision, and major loss of balance. Judgment and
perception are severely impaired. At a level of 0.20 a patient
may be dazed and confused and disoriented and may need
help to stand or walk. Pain response is blunted. Nausea and
vomiting are common. Gag reflex is impaired. Blackouts are
likely.
(Id. at 257.)
IV. Initial Decision and Review on Appeal
In a letter dated October 29, 2013, Standard informed Stephanie Giacomini of its
determination that no AD&D benefits were due her, “[b]ecause Mr. Giacomini was
legally intoxicated while operating a motor vehicle.” (Id. at 244.) On December 3, 2013,
Stephanie Giacomini’s counsel submitted an appeal from this claim denial. Among other
arguments, Giacomini’s counsel claimed that “motor vehicle” was an undefined term and
could “certainly be viewed as not extending to an all-terrain vehicle,” particularly in light
of Wisconsin statutes that exclude ATVs from the definition of “motor vehicle.” (Id. at
240.) Furthermore, the letter stated:
We would note that the initial investigation suggested that
Mr. Giacomini lost his hat prior to losing control of the
vehicle. It is certainly reasonable to believe that as the hat
flew off he reflexively reached to try to capture it, lost control
of the vehicle and crashed. That is a far more plausible
explanation than the notion that he braked and swerved
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suddenly to turn into a driveway that he had entered literally
hundreds of times before.
(Id. at 241.)
In a follow-up letter dated January 9, 2014, Giacomini’s counsel further noted
that “the model of ATV involved in this accident, the 2010 Polaris Sportsman XP 850,
has been the subject of a CPSC recall” because “the front suspension ball joint stem can
separate from the steering knuckle and cause the rider to lose steering control, posing a
risk of injury or death to riders.” (Id. at 233.) He characterized this information as “an
alternative explanation for the accident which is completely unrelated to intoxication.”
(Id.)
In response, Standard consulted a second physician, Brent Morgan, M.D., who
was Board Certified in Medical Toxicology and Emergency Medicine and worked as an
Associate Professor of Emergency Medicine at Emory University’s School of Medicine
and the Director of Grady Memorial Hospital’s Occupational and Environmental
Toxicology Clinic. Dr. Morgan performed a Physician Peer Review dated January 26,
2014. (Id. at 216.) In response to Standard’s request that Dr. Morgan comment on how
a BAC of 187 mg/dL would typically affect a person, Dr. Morgan stated:
Alcohol at a concentration of 187 mg/dL has clearly been
shown to decrease one’s ability to operate a motor vehicle
safely. Alcohol impairs consciousness, depth perception,
peripheral vision, reasoning, judgment, and concentration. In
addition, alcohol slows reflexes, slows reaction time, and
impairs gross motor control.
(Id.)
8
Standard also asked Dr. Morgan to opine as to whether the information in the
claim file supported “more reasonably than not that Mr. Giacomini’s ATV accident
and/or subsequent death were caused or contributed to by his legal intoxication while
operating a motor vehicle.” (Id. at 217.) Dr. Morgan responded in part:
[A]lcohol impairment of driving abilities begins to occur at 50
mg/dl or less. Any fatality occurring in a crash involving a
driver with a BAC of 80 mg/dl or higher is considered to be
an alcohol-impaired-driving fatality. . . . At a BAC of 80
mg/dl, drivers are so impaired that they are 11 times more
likely to have a single-vehicle crash than drivers with no
alcohol in their system. According to the Insurance Institute
for Highway Safety (IIHS) the relative risk of death for
drivers in single vehicle crashes with an elevated blood
alcohol is greater than 300 times that of sober drivers. . . . [I]t
is my opinion that more likely than not alcohol impairment
contributed to and/or directly caused Mr. Giacomini’s ATV
accident and subsequent death.
(Id.)
Standard also obtained a copy of the U.S. Consumer Product Safety
Commission’s recall, which applies to 2010 Sportsman XP 850 ATVs “with certain VIN
numbers” and advises consumers to “contact their local Polaris dealer to determine if
your model and VIN number are included in this recall.”
Standard then wrote to
Stephanie Giacomini’s counsel requesting: (1) verification that the recall applied to Karl
Giacomini’s ATV; and (2) documentation of any front suspension damage to or
malfunction in the ATV. (Id. at 195.) In response, via a letter dated March 10, 2014,
counsel provided the serial number, while noting that “we do not believe the recall is the
controlling fact in the case, although it is significant.” (Id. at 191.)
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V. Final Decision
On April 10, 2014, Standard’s Administrative Review Unit (“ARU”) notified
Stephanie Giacomini’s counsel that it had upheld the original determination that no
AD&D benefits were payable. (Id. at 166-74.) In particular, the ARU concluded that an
ATV qualified as a “motor vehicle” because Karl Giacomini had operated it on a highway
or roadway. The ARU also noted in the letter that no documentation supported the
alternate theory that Karl Giacomini had caused the accident by reflexively reaching for
his hat.
Furthermore, the letter concluded, Karl Giacomini’s intoxication had
contributed to his accident and death even if he had reached for his hat. The letter
pointed out that Stephanie Giacomini had neither submitted documentation showing
that the ATV was subject to the identified recall, nor had issues with the front-end
suspension.
Finally, the ARU claim file presented no evidence of a recall-related
malfunction that might have caused or contributed to the accident.
OPINION
I.
Standard of Review
When an ERISA challenge concerns a Policy that grants discretion to the
administrator or fiduciary to determine eligibility for benefits and construe plan terms,
courts ordinarily review a denial of benefits only to determine “whether the
administrator’s decision was ‘arbitrary and capricious.’” Holmstrom v. Metro. Life Ins. Co.,
615 F.3d 758, 766 (7th Cir. 2010) (quoting Metro. Life Ins. Co. v. Glenn, 554 U.S. 105,
111 (2008); Jenkins v. Price Waterhouse Long Term Disability Plan, 564 F.3d 856, 860-61
(7th Cir. 2009)). Not surprisingly, Standard’s motion for summary judgment invokes
10
this favorable analysis, reviewing in detail the evidence in the record that supports its
determination that Stephanie Giacomini is not entitled to any AD&D benefits under the
Policy.
In response, plaintiff does not argue that Standard’s decision was arbitrary and
capricious. Rather, she contends that Minnesota law renders the grant of discretion in
the Policy unenforceable, entitling her to a de novo review of her claims under Firestone
Tire and Rubber Company v. Bruch, 489 U.S. 101, 115 (1989). Beyond the straightforward
difference between a de novo and abuse of discretion standard of review, the applicable
standard may also affect what evidence the court considers in reviewing plaintiff’s claim
for benefits.
Under the deferential abuse of discretion standard, the court is limited to the
evidence in the administrative record. Hess v. Hartford Life & Accident Ins. Co., 274 F.3d
456, 462 (7th Cir. 2001). Under a de novo standard of review, in contrast, this court
would have “the discretion to ‘limit the evidence to the record before the plan
administrator, or . . . [to] permit the introduction of additional evidence necessary to
enable it to make an informed and independent judgment.’” Estate of Blanco v. Prudential
Ins. Co. of Am., 606 F.3d 399, 402 (7th Cir. 2010) (quoting Patton v. MFS/Sun Life Fin.
Distribs., Inc., 480 F.3d 478, 490 (7th Cir. 2007)); see also Patton, 480 F.3d at 490 n.7.
Accordingly, before reviewing Standard’s decision, the court first must determine the
appropriate standard of review.
Minnesota Statute § 62Q.107 contains a prohibition on discretionary clauses in
certain health insurance policies and states:
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Beginning January 1, 1999, no health plan, including the
coverages described in section 62A.011, subdivision 3, clauses
(7) and (10), 3 may specify a standard of review upon which a
court may review denial of a claim or of any other decision
made by a health plan company with respect to an enrollee.
This section prohibits limiting court review to a
determination of whether the health plan company’s decision
is arbitrary and capricious, an abuse of discretion, or any
other standard less favorable to the enrollee than a
preponderance of the evidence.
While ERISA generally supersedes “any and all State laws insofar as they may now
or hereafter relate to any employee benefit plan[,]”
29 U.S.C. § 1144(a), plaintiff
contends that ERISA’s savings clause, 29 U.S.C. § 1144(b)(2)(A), applies to Section
62Q.107 because it is a law “which regulates insurance.”
Legal authority for that
proposition is sparse. Plaintiff points out that various courts have concluded other states’
prohibitions on discretionary clauses fall within ERISA’s savings clause. See, e.g., Standard
Ins. Co. v. Morrison, 584 F.3d 837, 849 (9th Cir. 2009) (“[W]e agree with the district
court that the Commissioner’s practice of disapproving discretionary clauses is not
preempted by ERISA’s exclusive remedial scheme.”); Am. Council of Life Insurers v. Ross,
558 F.3d 600, 609 (6th Cir. 2009) (Michigan rules prohibiting discretionary clauses in
insurance contracts are not preempted); Curtis v. Hartford Life & Accident Ins. Co., No. 11
C 2448, 2012 WL 138608, at *10 (N.D. Ill. Jan. 18, 2012) (Illinois regulation
prohibiting discretionary clauses not preempted). But see Hancock v. Metro. Life Ins. Co.,
590 F.3d 1141, 1151-52 (10th Cir. 2009) (rule banning discretionary clauses in
The coverages described in clauses (7) and (10) are “blanket accident and sickness insurance as
defined in section 62A.11” and coverage “issued as a supplement to Medicare.” The AD&D
coverage does not qualify as either of these types of coverage.
3
12
insurance forms enforceable provided they comply with certain language and formatting
requirements found to be preempted by ERISA).
Assuming that the ERISA savings clause might be properly invoked by plaintiff
here, the court must still determine whether Minnesota Statute § 62Q.107 applies to the
facts before this court. As noted above, the statute by its terms prohibits discretionary
clauses in “health plans.”
“Health plan” is “defined in section 62A.011 or a policy,
contract, or certificate issued by a community integrated service network.” Minn. Stat.
§ 62Q.01, subd. 3. Section 62A.011, in turn, provides an extensive definition of “health
plan.” As it turns out, therefore, whether the AD&D coverage is a “health plan” within
the meaning of that statute determines its applicability.
In her brief in opposition to summary judgment, plaintiff points out that “health
plan” is defined in part as “a policy or certificate of accident and sickness insurance as
defined in section 62A.01 offered by an insurance company licensed under chapter
60A[.]” Minn. Stat. § 62Q.01, subd. 3. Section 62A.01 also provides that a “policy of
accident and sickness insurance” “includes any policy covering the kind of insurance
described in section 60A.06, subdivision 1, clause (5)(a).” Minn. Stat. § 62A.01, subd. 1.
Clause (5)(a) further reads that:
To insure against loss or damage by the sickness, bodily
injury or death by accident of the assured or dependents, or
those for whom the assured has assumed a portion of the
liability for the loss or damage, including liability for payment
of medical care costs or for provision of medical care.
Minn. Stat. § 60A.06, subd. 1, cl. (5)(a).
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In light of this definition, plaintiff argues that the AD&D coverage constitutes a
“policy or certificate of accident and sickness insurance,” emphasizing the fact that it
insures against “death by accident.” The court disagrees. While clause (5)(a) certainly
does insure against loss due to the insured’s “sickness, bodily injury or death by
accident,” it also requires that the coverage include “liability for payment of medical care
costs or for provision of medical care.”
Minn. Stat. § 60A.06, subd. 1, cl. (5)(a).
Plaintiff points to nothing in the Policy that suggests it provides for payment of medical
care costs.
Even if the Policy here met the definition in clause (5)(a), Standard cites to the
list of specific exclusions in the definition of a “health plan” found in Section 62A.011.
According to Standard, the AD&D coverage in the Policy falls within three of those
exclusions:
Health plan does not include coverage that is:
(1) limited to disability or income protection coverage; . . .
(4) designed solely to provide payments on a per diem, fixed
indemnity, or non-expense-incurred basis, including coverage
only for a specified disease or illness or hospital indemnity or
other fixed indemnity insurance, if the benefits are provided
under a separate policy, certificate, or contract for insurance;
there is no coordination between the provision of benefits
and any exclusion of benefits under any group health plan
maintained by the same plan sponsor; and the benefits are
paid with respect to an event without regard to whether
benefits are provided with respect to such an event under any
group health plan maintained by the same plan sponsor; . . .
[or]
(8) accident-only coverage[.]
Minn. Stat. § 62A.011, subd. 3.
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If any of these three exclusions applies, the Policy does not constitute a “health
plan” and is not subject to § 62Q.107’s prohibition on discretionary clauses. Cf. Dehart
v. Life Ins. Co. of N. Am., No. 2:11-cv-11806, 2013 WL 4777184, at *4 (E.D. Mich. Sept.
5, 2013) (declining to invalidate discretionary clause under Section 62Q.107 where
ERISA plan provided only long-term-disability benefits); Sullivan v. Unum Life Ins. Co. of
Am., No. 10-4076, 2011 WL 3837134, at *6-7 (D. Minn. Aug. 26, 2011) (declining to
invalidate discretionary clause under Section 62Q.107 where ERISA plan “primarily
provide[d] income protection”), rev’d on other grounds sub nom Govrik v. Unum Life Ins. Co.
of Am., 702 F.3d 1103 (8th Cir. 2013).
Here, too, the court agrees with Standard that the Policy fits at least one of these
exclusions.
Without expressing an opinion as to whether the Policy is “limited to
disability or income protection coverage” or “accident-only coverage,” the court agrees
that it is designed to provide payments on a fixed indemnity/non-expense-incurred basis
under Section 62A.011. 4 The Policy itself indicates that the AD&D benefit payable is
equal to the member’s Plan 1 (basic) Life Insurance Benefit. (AR 67.) Since neither the
AD&D benefit nor the life insurance coverage makes reference to expenses incurred, and
the Policy as a whole lacks any coordination with, or reference to, a group health plan,
There appears to be uncertainty as to whether the court must assess the Policy as a whole in
determining whether it fits within the definition of “health plan” or just the AD&D coverage
provision actually at issue in this suit. Compare Dehart, 2013 WL 4777184, at *4 (noting that
“the policy at issue concerns only LTD benefits and is not a ‘health plan’ under Minnesota law”),
with Minn. Stat. § 62A.011, subd. 3 (stating that the term “health plan” “does not include
coverage” that fits within one of the listed categories) (emphasis added). If the court need only
assess the AD&D coverage portion of the Policy to determine whether it is a health plan, then it
would on its face be excluded as “accident-only coverage.” (See AR 138 (benefits payable only if
loss is “caused solely and directly by an accident”).) Because the Policy as a whole is not so
limited, however, the court assesses the entire Policy in determining whether it constitutes a
“health plan,” without deciding whether this broader review is actually required.
4
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the Policy is not a “health plan” within the meaning of Section 62Q.107 and the
accompanying prohibition on discretionary clauses does not apply.
Accordingly, this
court must review Standard’s decision under the arbitrary and capricious standard
adopted by the plan. See Dehart, 2013 WL 4777184, at *4-8 (rejecting application of
Section 62Q.107 and concluding that decision was not arbitrary and capricious). 5
II.
Merits Review
“The scope of review under the ‘arbitrary and capricious’ standard is narrow and a
court is not to substitute its judgment for that of [an ERISA fiduciary].” Reilly v. Blue
Cross & Blue Shield United of Wis., 846 F.2d 416, 420 (7th Cir. 1988) (quoting Motor
Vehicle Mfrs. Ass’n of the U.S., Inc. v. State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43
(1983) (alterations in original)).
While this court owes the administrator significant
deference, the Seventh Circuit has nevertheless cautioned that “[r]eview under this
standard is not a rubber stamp,” Holmstrom, 615 F.3d at 766, and “deference need not be
abject,” Gallo v. Amoco Corp., 102 F.3d 918, 922 (7th Cir. 1996). Instead, the court is to
uphold an administrator’s decision “if (1) it is possible to offer a reasoned explanation,
based on the evidence, for a particular outcome, (2) the decision is based on a reasonable
explanation of relevant plan documents, or (3) the administrator has based its decision
on a consideration of the relevant factors that encompass important aspects of the
problem.” Militello v. Cent. States, Se. & Sw. Areas Pension Fund, 360 F.3d 681, 686 (7th
Because the court concludes that Section 62Q.107 does not apply here, it need not consider
whether that statute would be preempted by ERISA or whether it is appropriate to apply
Minnesota law.
5
16
Cir. 2004) (internal quotation marks and citations omitted). Likewise, the court is to
uphold an administrator’s interpretation of an ERISA plan so long as it is reasonable.
Conkright v. Frommert, 559 U.S. 506, 521 (2010).
Under this deferential standard, Standard’s decision to deny AD&D benefits
cannot be characterized as arbitrary and capricious. With respect to its interpretation of
the Policy, AD&D benefits are not payable when “legal intoxication while operating a
motor vehicle” either causes or contributes to the accident or loss.
Given that Karl
Giacomini’s blood alcohol concentration was more than twice Wisconsin’s legal limit of
0.08, he was undoubtedly legally intoxicated while operating his ATV. See Wis. Stat.
§ 23.33(4c)(a)(2) (“No person may engage in the operation of an all-terrain vehicle or
utility terrain vehicle while the person has an alcohol concentration of 0.08 or more.”).
Similarly, ATVs are vehicles propelled by tires on a motor, and Karl Giacomini was
driving his on a public roadway. Nothing about Standard’s interpretation of the term
“motor vehicle” to include an ATV, at least under those circumstances, is unreasonable.
There is likewise ample evidence to support Standard’s conclusion that Karl
Giacomini’s intoxication while operating the ATV caused or contributed to his death.
Standard had before it various reports from officials who responded to the accident
scene, including interviews with witnesses who confirmed that Karl Giacomini had been
drinking. It had blood test results demonstrating that his BAC was .187 soon after the
accident, significantly over the legal limit. It had the memorandum from Dr. Beeson
indicating that someone with Karl Giacomini’s BAC would “have significant gross motor
impairment, lack of physical control, blurred vision, and major loss of balance” as well as
17
“severely impaired” judgment and perception. Furthermore, when plaintiff appealed the
denial of coverage, Standard obtained an additional medical opinion, which supported its
initial conclusion that Karl Giacomini’s legal intoxication while operating the ATV
caused or contributed to his death.
It also investigated the alternative cause that
plaintiff’s counsel proposed -- the ATV recall -- and obtained no evidence that
mechanical failure played any part in the accident. Overall, it is undoubtedly “possible to
offer a reasoned explanation, based on the evidence, for” Standard’s determination.
Militello, 360 F.3d at 686.
Notably, plaintiff does not actually brief the question of whether Standard’s
decision was arbitrary and capricious; her opposition is limited to her contention that
this court must review Standard’s decision de novo, which the court rejected above. As
such, she has essentially waived any opposition on those grounds. See Bonte v. U.S. Bank,
N.A., 624 F.3d 461, 466 (7th Cir. 2010) (“Failure to respond to an argument . . . results
in waiver.”). She does purport to dispute some of defendant’s proposed findings of fact
on the grounds that there is insufficient evidence to establish the truth of those facts -for example, she admits that Dr. Beeson opined that a patient with a BAC of .187 would
have “significant gross motor impairment, lack of physical control, blurred vision, and
major loss of balance,” but argues that there is no evidence that Karl Giacomini actually
suffered from those symptoms when the accident occurred. (Pl.’s Resp. DPFOF (dkt.
#25) ¶ 29.) To the extent this is intended to serve as an argument that Standard’s
decision was arbitrary and capricious, the court disagrees.
This court must only
determine whether Standard’s decision has rational support in the record, Becker v.
18
Chrysler LLC Health Care Benefits Plan, 691 F.3d 879, 885 (7th Cir. 2012), not whether
the decision was right, Hightshue v. AIG Life Ins. Co., 135 F.3d 1144, 1147 (7th Cir.
1998). The reports from the law enforcement officials who responded to the scene of the
accident, coupled with the opinions of the two physician consultants, undoubtedly
provide “rational support” for Standard’s determination at the very least.
Finally, the court notes that, even faced with a motion for summary judgment,
plaintiff cited no evidence tending to undermine the evidence on which Standard relied,
nor did she point to any evidence in the administrative record that supports an alternate
theory of causation.
See Armato v. Grounds, 766 F.3d 713, 719 (7th Cir. 2014)
(“Inferences that rely upon speculation or conjecture are insufficient” to avoid summary
judgment). The court is not required to search the record for such evidence or piece
together arguments on plaintiff’s behalf. Diadenko v. Folino, 741 F.3d 751, 757 (7th Cir.
2013).
Plaintiff has undoubtedly suffered a tragedy, and the court is sympathetic to her
loss. However, given the record before this court -- including law enforcement reports
and opinions from multiple physician consultants -- the court is unable to find Standard
acted arbitrarily or capriciously in finding that Karl Giacomini’s legal intoxication while
operating a motor vehicle caused or contributed to his accident, which excepts the
accident from the sphere of covered “loss” under the terms of the Policy’s AD&D
provision. Accordingly, plaintiff has failed to show that a genuine dispute of fact remains
for trial, and Standard is entitled to summary judgment in its favor.
19
ORDER
IT IS ORDERED that:
1) Defendant Standard Insurance Company’s motion for summary judgment
(dkt. #15) is GRANTED.
2) The clerk of court is directed to enter judgment and close this case.
Entered this 15th day of September, 2015.
BY THE COURT:
/s/
________________________________________
WILLIAM M. CONLEY
District Judge
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