TIM LEONARD, District Judge.
Plaintiffs Eldon Goeringer and Leta Sue Goeringer filed this complaint pursuant to the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a), alleging that defendant Sun Life Assurance Company of Canada wrongfully denied their claim for accidental death benefits. The parties agreed that this case may be submitted to the court on the administrative record and simultaneously filed opening and reply briefs. Having considered the administrative record (cited as "AR ___") and the parties' briefs on the merits, the court finds that the decision denying plaintiffs' claim for accidental death benefits should be affirmed, for the reasons stated below.
Plaintiffs' son, Eugene Allen Goeringer, was employed by Warren CAT of Oklahoma City, Oklahoma, a division of Warren Equipment Company of Midland, Texas, as a field service technician. AR 1. A policy insuring Warren Equipment Company's employee benefit plan was issued by defendant, Sun Life Assurance Company of Canada ("Sun Life"). AR 96. In addition to disability coverage, the policy provided Basic Life and Accidental Death and Dismemberment coverage as well as Employee Optional Life and Accidental Death and Dismemberment coverage. AR 96. Mr. Goeringer elected three times his annual earnings of optional accidental health coverage, in addition to the basic accidental death benefits provided by his employer. AR 13. Mr. Goeringer designated his parents, the plaintiffs herein, as the beneficiaries of his accidental death insurance coverage. AR 13, 14. It is undisputed that the policy provided Sun Life with "entire discretionary authority to make all final determinations regarding claims for benefits" including, but not limited to, "the determination of eligibility for benefits. . . and the amount of any benefits due, and to construe the terms" of the policy. AR 163.
According to the Piedmont Police Department Incident Report, Mr. Goeringer was found dead in the garage of his Piedmont, Oklahoma residence on December 10, 2009. AR 19, 37.
The record reflects that Mr. Goeringer's amended death certificate identifies the immediate cause of his death as "acute carbon monoxide intoxication." AR 4. Another significant condition contributing to the death is stated as "acute ethanol intoxication."
On or about January 15, 2010, plaintiffs submitted timely claims to Sun Life for life insurance benefits and accidental death benefits under the policy. AR 5-12. On or about February 19, 2010, Sun Life notified Mr. Goeringer's employer, Warren Equipment Company, that it was paying Mr. Goeringer's life insurance benefits, but was continuing to review the claim for accidental death benefits. AR 33.
In letters dated May 14, 2010, Sun Life advised the plaintiffs that it was denying the accidental death benefit claims pursuant to the terms of the policy. The denial letters, AR 43-48, quote the following policy provisions, taken from Section IV of the Benefit Provisions section regarding Employee Accidental Death and Dismemberment Insurance (see AR 131, 133):
The denial letters further state that it is illegal to operate a motor vehicle in Oklahoma with a blood alcohol level of .08 or greater. AR 43, 46.
Plaintiffs made a timely request for administrative review of the denial of accidental death benefits. AR 50-54. On review, Sun Life refused to alter its decision that accidental death insurance benefits were not payable under the terms of the policy. AR 77-83. This lawsuit followed.
Where, as here, the plan grants a plan administrator discretion in determining the grant of benefits under the plan, the court must uphold the decision of the administrator unless the court finds that the determination was arbitrary and capricious.
A lack of substantial evidence may indicate an arbitrary and capricious decision.
It is undisputed that Sun Life determines eligibility under the plan and pays benefits under the plan. This dual role creates a conflict of interest.
Mindful of the appropriate standard of review, the court finds that Sun Life's decision to deny plaintiffs' claim for accidental death benefits in this case does not indicate a likelihood that Sun Life's dual role affected its denial decision. Because Sun Life's decision was amply supported by substantial evidence in the administrative record, the court agrees with Sun Life that this is a case in which the conflict of interest is not a significant factor.
Sun Life argues that Mr. Goeringer's death is excluded from coverage under the policy because it was due to his operation of a motorized vehicle while intoxicated. As for its decision that Mr. Goeringer was operating a motor vehicle, Sun Life has pointed to facts in the record indicating that Mr. Goeringer's body was found in the driver's seat of his truck (AR 19), the truck's battery was dead and the ignition to the vehicle was in the "on" position (AR 19). Sun Life decided that Mr. Goeringer was operating the truck at the time of his death based on the Medical Examiner's conclusion that the cause of death was due to acute carbon monoxide intoxication, and the fact that the door to the garage where the truck was located was in the closed position.
As for its finding that Mr. Goeringer was intoxicated under the terms of the policy, Sun Life relies on the language of the policy itself which defines the term "intoxication" as "the minimum blood alcohol level required to be considered operating an automobile under the influence of alcohol in the jurisdiction where the accident occurred." AR 133. Citing 47 O.S. § 11-902(a)(1), Sun Life maintains that, under Oklahoma law, a person is driving while intoxicated at a blood alcohol level of .08. Since the administrative record indicates that Mr. Goeringer's blood alcohol level was determined to be above this level, at .17%, and the Medical Examiner further identified "acute ethanol intoxication" as a significant medical condition which led to Mr. Goeringer's death, Sun Life argues that its conclusions in this regard are also supported by substantial evidence.
Sun Life also determined that accidental death benefits were not payable under the policy because the death was excluded from coverage due to "intentionally self-inflicted injuries." AR 44, 47. Based upon the information it had received, and the words of the policy, Sun Life concluded that: "The injuries resulting in Mr. Goeringer's death were reasonably foreseeable and were the natural and probable result of conduct knowingly undertaken and therefore Mr. Goeringer's death was not accidental. The injuries resulting in Mr. Goeringer's death were self-inflicted."
In reviewing the reasonableness of Sun Life's decision, the court has carefully considered the arguments and contentions of the plaintiffs, however, the court finds that they are insufficient to justify overturning Sun Life's denial decision, given the applicable standard of review. Plaintiffs submit that Sun Life's denial of accidental death benefits based on its determination that Mr. Goeringer was operating a motor vehicle while intoxicated was arbitrary and capricious and an abuse of discretion.
Plaintiffs' remaining attempts to undermine the denial are speculative and rely upon scenarios that are not present in the administrative record in this case. The court's review is limited to the administrative record, and "[a]n administrator's decision is not arbitrary or capricious for failing to take into account evidence not before it."
The court concludes that the record clearly includes substantial evidence that Mr. Goeringer's death, though certainly tragic, was the result of his operation of his truck while intoxicated. In light of this conclusion, the court need not determine whether Sun Life properly applied the exclusion for "intentionally self-inflicted injuries."
AR 83.
The court cannot say that Sun Life's decision to deny accidental death benefits was not grounded on any reasonable basis. Having thoroughly reviewed the entire administrative record, the court concludes that Sun Life's decision denying plaintiffs' claim for accidental death benefits should be upheld.
Accordingly, for the above stated reasons, Sun Life's decision denying plaintiffs' claim for accidental death benefits should be and is hereby
It is so ordered.