Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_05-cv-01131/USCOURTS-almd-2_05-cv-01131-3/pdf.json

Parties Involved:
MeadWestvaco Corporation
Defendant
Stephen L. Miller
Plaintiff
ReliaStar Life Insurance Company
Defendant

Document Text:

IN THE DISTRICT COURT OF THE UNITED STATES FOR THE

MIDDLE DISTRICT OF ALABAMA, NORTHERN DIVISION

STEPHEN L. MILLER, )

)

Plaintiff, )

) CIVIL ACTION NO.

v. ) 2:05cv1131-MHT

) (WO) 

RELIASTAR LIFE INSURANCE )

COMPANY, a corporation, )

)

Defendant. )

OPINION

At issue in this case, on defendant ReliaStar Life

Insurance Company’s motion for summary judgment, is

whether ReliaStar’s decision to deny plaintiff Stephen L.

Miller’s accidental dismemberment claim was permissible

under the Employee Retirement Income Security Act of 1974

(“ERISA”), 29 U.S.C. §§ 1001-1461. The court has

jurisdiction pursuant to 29 U.S.C. § 1132(e)(1). For the

reasons that follow, the court finds that the decision

was permissible and thus that summary judgment should be

entered in favor of ReliaStar. 

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 1 of 12
2

I. APPLICABLE LEGAL STANDARDS

The parties agree that the ERISA standard for

evaluating ReliaStar’s decision denying benefits to

Miller is the following six-part test:

“(1) Apply the de novo standard to

determine whether the claim

administrator's benefits-denial decision

is ‘wrong’ (i.e., the court disagrees

with the administrator's decision); if

it is not, then end the inquiry and

affirm the decision.

“(2) If the administrator's decision in

fact is ‘de novo wrong,’ then determine

whether he was vested with discretion in

reviewing claims; if not, end judicial

inquiry and reverse the decision.

“(3) If the administrator's decision is

‘de novo wrong’ and he was vested with

discretion in reviewing claims, then

determine whether ‘reasonable’ grounds

supported it (hence, review his decision

under the more deferential arbitrary and

capricious standard).

“(4) If no reasonable grounds exist,

then end the inquiry and reverse the

administrator's decision; if reasonable

grounds do exist, then determine if he

operated under a conflict of interest.

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 2 of 12
3

(5) If there is no conflict, then end

the inquiry and affirm the decision.

“(6) If there is a conflict of interest,

then apply heightened arbitrary and

capricious review to the decision to

affirm or deny it.”

Williams v. BellSouth Telecommunications, Inc., 373 F.3d

1132, 1138 (11th Cir. 2004). 

In addition, because this case is before the court on

ReliaStar’s summary-judgment motion, the court may find

in favor of ReliaStar only “if the pleadings,

depositions, answers to interrogatories, and admissions

on file, together with the affidavits, if any, show that

there is no genuine issue as to any material fact and

that [ReliaStar] is entitled to a judgment as a matter of

law.” Fed. R. Civ. P. 56(c). 

II. BACKGROUND

The facts, according to Miller, are as follows: On

August 13, 2004, Miller was working on his R.V. and hit

his head on the hitch. His vision became blurred that

night and continued to worsen. He saw Dr. Ebrahim about

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 3 of 12
4

the loss of vision in his right eye, and Dr. Ebrahim

referred him to Dr. Allan Kelley, an ophthalmologist. Dr

Kelley’s impression was that Miller’s vision loss was a

result of nonarteritic anterior ischemic optic neuropathy

(“NAION”), a condition, the parties agree, that is not

induced by trauma and that would be consistent with

Miller’s high blood pressure. 

Dr. Kelley referred Miller to Dr. David Turok, who

initially echoed Dr. Kelley’s impression of NAION, but

ordered an MRI, bloodwork, and, eventually, a Visual

Evoked Potentials test. The MRI showed no abnormality,

although the Visual Evoked Potentials test did. 

Although Dr. Turok’s initial impression was NAION, he

noted in his Attending Physician’s Statement that the

optic neuropathy--whether traumatic or NAION--was

“possibly traumatic,” and, where the form inquired

whether the injury was traumatic, he answered “possibly.”

Miller, then an employee of MeadWestVaco Corporation,

filed a claim under the Accidental Death and

Dismemberment Plan MeadWestVaco had with Reliastar.

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 4 of 12
5

ReliaStar denied the claim, concluding that Miller’s loss

of sight was due to an existing medical condition and not

an accident. 

After learning that Miller had been denied benefits,

Dr. Turok reviewed Miller’s records and wrote a letter

“clarifying” that the loss of vision was due to an

accident. He based this clarification on the temporal

proximity between the accident and the vision loss.

Miller appealed up the ranks within Reliastar, and

submitted Dr. Turok’s clarification in support of his

appeal. ReliaStar asked Dr. Mark Johnson, an internal

medicine specialist, to review Miller’s records to

determine if his vision loss was the result of an

accident. Dr. Johnson found that it was not; his

conclusion was that there was “no documentation in the

records to indicate that the original diagnosis of

ischemic optic neuropathy was incorrect, and this is a

condition unrelated to trauma.” 

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 5 of 12
6

Relying on Dr. Johnson’s opinion, ReliaStar

reaffirmed its denial benefits to Miller. Miller then

brought this lawsuit challenging that decision. 

III. DISCUSSION: WAS THE ADMINISTRATOR’S 

DECISION “WRONG”?

Because Miller has not raised an issue of fact as to

whether the administrator’s decision was “wrong,”

Williams, 373 F.3d at 1138, this court need not go beyond

the first step of the six-step ERISA analysis. In other

words, the evidence unequivocally supports the

administrator’s decision. 

The plan provides that “ReliaStar pays [the

appropriate accidental dismemberment] benefit if you lose

your life, limb or sight due to an accident.” An

accident, in turn, is defined as, “an unexpected,

external, violent and sudden event.” The policy excludes

loss “directly or indirectly related to physical or

mental illness.”

ReliaStar denied Miller’s claim on the rationale that

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 6 of 12
7

“the medical records [it] received do not document any

accidental injury.” It based its denial on the opinion

of Dr. Johnson, who found that “there is no medical

evidence in the records to establish a cause and effect

relationship between the head bump and the visual loss.”

In particular, Dr. Johnson was impressed that Miller “did

not sustain[] any damage to his head, eye, or any other

portion of his body when he bumped his head on his R.V.”

Essentially, ReliaStar’s determination of eligibility

presented ReliaStar with a choice between two equally

likely causes of his vision loss: either that Miller’s

high blood pressure caused NAION or that Miller’s bumping

his head on his R.V. caused traumatic injury to the optic

nerve. The doctors pointed to no definitive evidence

that the injury was traumatic, nor to any that it was

caused by high blood pressure. Rather, Dr. Turok was

swayed by the temporal proximity between the accident and

the vision loss and suggested that the cause was

traumatic. Dr. Johnson, by contrast, was swayed by

Miller’s high blood pressure and the lack of evidence of

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 7 of 12
8

an accident. Their conclusions are equally likely, given

the evidence available to the court. The trauma and the

high blood pressure have both temporal proximity to the

vision loss, and a tendency to cause vision loss.

However, there is no evidence that one is any more likely

to have caused the loss than the other. ReliaStar, given

this situation, denied benefits.

In rejecting Miller’s claim, the administrator

correctly determined that Miller bore the burden of

proving that his accident was the cause of his injury,

Horton v. Reliance Standard Life Ins. Co., 141 F.3d 1038,

1040 (11th Cir. 1998), and that Miller failed to meet

this burden in that it does not appear more likely than

not that the injury was the result of an accident.

Because Miller bears the burden, if he cannot demonstrate

that it is more likely than not that an injury caused the

accident, the administrator is entitled to deny benefits.

See, e.g., Houchens v. American Home Assur. Co., 927 F.2d

163, 167 (4th Cir. 1991) (where plaintiff bore the burden

of demonstrating, in order to recover under accidental

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 8 of 12
9

death policy, that death was an accident, and the

evidence showed that it was as likely that death was not

an accident, as it was likely that death had been an

accident, plaintiff did not raise issue of material

fact).

Miller nonetheless argues that ReliaStar bears the

burden here, because, where an “insurer claims that a

specific policy exclusion applies to deny the insured

benefits, the insurer generally must prove the exclusion

prevents coverage,” id., and the decision to deny

benefits was the application of an exclusion. 

While it is true that there is a relevant exclusion

in the plan, this is not the provision upon which

ReliaStar based its denial of benefits. ReliaStar found

that Miller did not qualify for benefits at all, not that

he fell into a policy exclusion. Specifically, ReliaStar

found that he did not qualify under the provision of the

contract that provides that “ReliaStar pays this benefit

if you lose your life, limb or sight due to an accident.”

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 9 of 12
10

Miller attempts to avoid bearing the burden in the

event that the policy exclusion is not at issue, by

pointing out that there is no causation requirement in

Reliastar’s definition of an accident as “an unexpected,

external, violent and sudden event.” While this may be

so, there is an obvious causation requirement in the

entitlement provision: “ReliaStar pays this benefit if

you lose your life, limb or sight due to an accident.”

This language--in particular, its “due to”

phrase--unambiguously requires that, to qualify for a

benefit, there be a causal connection between the

accident and the injury. While, as the Eleventh Circuit

Court of Appeals has recognized with respect to similar

language, there may not need to be total identity between

the accident and injury, such language nonetheless

requires some causal link between an accident and the

injury. Dixon v. Life Ins. Co. of North America, 389

F.3d 1179, 1184 (11th Cir. 2004). It was, therefore, not

wrong for the administrator to deny the Miller benefits.

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 10 of 12
11

Admittedly, as Miller notes in his brief in

opposition to summary judgment, there is a note in Dr.

Kelley’s initial records that the referring physician

noticed blood in Miller’s eye. None of the doctors in

this case, including Miller’s own supporting physician,

Dr. Turok, finds any significance in this fact, and, in

particular, none of the doctors states that this fact

suggests that Miller’s loss of sight was due to trauma.

Indeed, there is nothing in the record as to whether

Miller had blood in his eye before he allegedly hit is

head. Argument in a brief, without supporting testimony

in the record from a medical expert, is inadequate to

serve a basis for a finding that the notation in a

doctor’s record of blood in Miller’s eye indicates that

the loss of his sight was, or even could be, due to

trauma and thus is adequate for this court to hold that

Reliastar’s decision denying benefits was wrong.

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 11 of 12
IV. CONCLUSION

Because Miller has failed to carry his burden of

presenting sufficient evidence that it is more likely

than not that an accident caused the blindness in his

right eye, ReliaStar is entitled to summary judgment. An

appropriate judgment will be entered. 

DONE, this the 21st day of November.

 /s/ Myron H. Thompson 

UNITED STATES DISTRICT JUDGE

Case 2:05-cv-01131-MHT-DRB Document 44 Filed 11/21/06 Page 12 of 12