1 NO T R EC OM M EN DE D F OR F UL L- TEX T P UB LIC AT ION F ile Nam e: 10a0171n.06 No. 08-6522 UN ITED STA TES C OU RT OF AP P EA LS F OR THE SI XT H C IR CU IT MI M I LO A N ; A SH LE Y LO A N ; A M A N DA LOAN, P lai nt iffs- App e lla nt s,
v. P RU DE NT IA L INSU RA NC E COM P AN Y O F AMERICA, Defendan t-Appellee. / ON AP P EA L F RO M THE U NI TED STA TES D ISTRIC T C OU RT F OR THE EA S TE RN D IS TR IC T O F K EN TU CKY

BEF OR E: G UY , C LA Y, and W HIT E, C ir c uitJudg e s. CLAY, Circ uit Jud ge. Plaintiffs, Mimi L oan, Ashley L oan, and A man da L oan appe al pursuant to the Employ ee Retirement I ncome Security Act of 1974 (“ERI SA”), 29 U.S.C. § 1132, from the dist rict court’s order aff irming the administrative denial by Def endant Prude ntial I nsuranc e Company of Amer ica ( “Prudential” ) of a ccide ntal death be nefits to Plaintiffs. For the r easons se t f o rt h b e l o w , w e h e r e b y VA CA TE the district c ourt’s orde r and REMAND fo r f u rt h er p ro ce ed i n gs consistent with this opi nion.2 BACK GR OUND At approximately

7:30 p.m. on June 29, 2006, Ernest Hollis L oan, a 53- y ear -old, 205 pound
man, fe ll d ow n tw o f

lig hts of sta ir s w hil e a tte mpt ingto d e sc e nd his ba se me nt s te ps . A c c or din g to Mr. L oan’s wif

e, Mimi L oan, Mr. L oan had c onsumed three g lasses of wine betwee n 5:30 p.m. and 7:00 p.m. Mrs. L oan indicate d that Mr. L oan had just complete d a business transa ction over the phone and w as helping her w ith a home repair at the t ime of hi s fall. She further stated that he w as not impaired in his motor skill s, speec h, or balance. At the time, Mr. L oan wa s taking an over -thecounter cold medication and Clonazepam, presc ribed by a doctor to treat de pression. Following the fa ll, Mr. L oan wa s transported by ambu lance to the University of Ke ntucky C h an d l er M ed i ca l C en t er . At ap p ro x i m at el y 8 : 4 8 p . m . , M r. L o an ’s b l o o d wa s dra wn . A t o x i co l o gy
r e p o rt g e n e r a t e d f

r o m t h i s b l o o d s a mp l e i n d i c a t e s M r . Lo an ’ s p l a s m a a l c o h o l l e v e l w a s 1 7 8 m g / d L. Mr. L oan re mained in cr itical condition in the neurosurg ery intensive ca

re unit for approximately

one we ek. On July 6 , 2006, Mr. L oan wa s removed f rom life support and pa ssed
a wa y . Ac c or d i n g t o h i s d e a t h c e rt i f i c a t e , M r . L o and i e d

o f b l u n tf o r c e h e a d t r a u m a d u e t o a f a ll down the stairs. Plaintiffs, Mr. L oan’s widow a nd his two children, are named beneficia ries under his gr oup
acc idental death insurance poli cy . T he policy was issued by

Prudential throug h Mr. L oan’s
e mpl oy e r, B ay e r Cor

po ratio n, and pa

y s $3 00 ,0 00
. Un de r the po lic y , Pr ud e nti a l a c ts a s the Cla ims Administrator wi th “sole discre tion to int erpr et the ter ms of the Group Contra ct, to make f actua l fi nd ing s, and

to d e te rm ine e lig ibi lity

fo r b e ne fi ts. ” Th e po lic y fu rt he r p ro vid e s: B e ne fi ts f or a c c ide nta l L os s are pa

y a ble on ly if a ll the se c on dit ion s a

re me t: (1) The person sustains an a ccide ntal bodily injury while a Cover ed Person.3

(2) The L oss results directly from that Injury

and fr om no other ca

use.

. . . A L oss is not covered if

it results from any

of these:

. . . (9 ) B e ingle g a lly

int oxic a te d o r u

nd e r t he inf lue nc e of any na rc oti c un le ss administered or

consumed on the a dvice of a Doc tor . . . (App. at 137-39). Following Mr. L oan’s de ath, Plaintiffs submitt ed a c laim for the f ull p o l i cy amount. On November

7, 2006, Prudential sent a letter to Plainti ffs deny ing their claim, citi ng Mr. L oan’s a lleg ed intoxi c a ti o n a t th e ti me o f h is f a ll
. O n N o v e mb e r 2 7 , 2 0 0 6 , Pl a in ti f f s a p p e a le d th e decision. On April 26, 2007, Prudential denied the appea l and upheld th e d ec ision to di sallow the cla im for
acc idental death benef

its. I n the initial and seconda

ry revie w of Plaintiffs’ claim, Prudential used in-house doctors who
wer e not experts in tox icolog y to reviewthe tox icolog y repor t perfor med on the dec edent . I n the ini tia l r e vie w, Dr . K ow a lsk i no te d th a t “ e tha no l or a lc oh ol l e ve ls a

re determine d b y

us ingwh ole blood rather t han plasma.” (App. at 124). Since plasma wa s used in this case, Dr . Kowalski
conver ted the plasma e thanol level into a blood ethanol leve l using the most conse rvative c onversion fra ction and found that Mr. L oan’s blood a lcohol level was 146 mg/dL
. A blood alcohol level of 146 ml/dL is equivalent to 0.146 perc ent. He note d that Mr. L oan’s blood a lcohol content (“B AC”) wa s
a pp ro xima te ly

1. 8 ti me s th e ty

pic a l dr ivi ng lim it in mos t state s, wh ic h is 80 mg /dL or 0. 08 pe rc e nt. On a pp e a l, D r. Ma c B ri de c on c lud e d th a t the e xce ss of e tha no l in Mr . L oa n’ s sy ste m do c ume nte d in the tox icolog y

repor t indicated that Mr. L oan’s “ fall occ urre d concur rently wi t h t h e p rese nce of a BA C in ex cess of

the leg al limit.” (App. at 122).This Co u rt h as i nterpre ted Supreme Court pre cede nt to say that if the plan g ives the 1 administrator discre tionary authority , this Court m ust review the administrator’s decision under the highly defe rential arbitra

ry and ca pricious standar d. See, e .g., Smith v. Health Serv s. of Coshocton , 314 F. App’x 848, 854 (6th Cir. 2009) . Fur thermore , the district court in the instant ca se applied the arbitra ry and capricious st andar d of re view. Howe ver, in Glenn , the Supreme Court made clea r that a c ourt re vie wi nga

de c isi on ma de by a pla

n a dmi nis tr a tor wi th d isc re tio na ry a uth or ity sh ou ld a pp ly the hi g hly defe rential a

buse of discr etion standard. Glenn , 128 S. Ct. at 2348. Acc ording ly , we have fo llo we d th e sta

nd ard se t out by

the Sup re me Court
.

4 On J anuar

y 28, 2008, plaintiffs filed a complaint with the district court, see king a ccide ntal death be nefits under

ERI SA. On Dec ember

4, 2008, the district court a ffirme d Prudential’s denia l of ac cidental de ath benefits to Plaintiffs. On Dec ember 19, 2008, Plaintiffs filed a timely notice of
a pp e a l. DI SCU SSIO N I. Stand ard of Review “[T] his Court ‘review [s] de novo the de cis i o n o f a d istrict court g ranting judgme nt in an ERI SA disabilit y

benef it action based on an adminis trative recor d,’ applying the same leg al standar d as does the district c ourt.” W enner v . Sun Life AssuranceCo. of Can. , 482 F.3d 878, 881 ( 6th Cir. 2 0 0 7 ) ( qu o t i n g Gl e nn v . M e tLif e , 461 F .3 d 660 , 665 -6 6 (6t h Cir. 20 06 ))
. I f a pla

n pro vid e s a

c la ims
a dmi nis tr a tor

wi th dis c re tio na

ry a uth or ity to int e rp re t th e te rm s o f t he pla n o r d e te rm ine e lig ibi lity for be n e f it s , a d is tric t court will review

the administrator’s de termination under the highly defe rential abuse of discretion st andar d. See M etropolitan L ife Ins. Co. v. Glenn , 128 S. Ct . 2343, 2348, 171 L
. E d
. 2 d 2 9 9 (2 0 0 8 ) ( ci t i n g Firestone Tire & Rubber Co. v . Bruch , 489 U. S. 1 01 , 1 11 , 1 09 S. Ct
. 9 4 8 , 1 0 3 L
. E d
. 2 d

8 0 ( 1 9 8 9 ) )
. W h e r e ana d m i n i s t r a t o r b o t h e v a l u a t e s c l a i m s f

o r b e n e f i t s an d p ays 1 benef its claims, the admini strator is operating under a conflict of inter est, and the c ourt weig hs that conflict a s a fa ctor in dete rmining w hether the administrator a

bused its discretion. Id.5

Be cause the plan at issue pr ovides P ru d en t i al with discretion, we a pply the abuse of discretion s t an dard of

revie w. Fur

thermore , since Prudential wa s operating unde r a c onflict of interest, we must weig h that conflict of inter est as a f actor in de termining whether Prudential abused its dis c re tio n b y

de nyinga c c ide nta l de a th b e ne fi ts t o Pl a int if fs
. “[A]n abuse of di scre tion exis ts only when the court has the definite and firm conviction that the district court made a clear error of j udg ment in its conclusion upon weig hing r eleva nt fac tors.” G a e th v . H

a r tf o rd Li fe Ins. Co. , 5 3 8 F.3d 524, 528- 29 (6th Cir. 2008) (quoting Moon v. U num Provident Co rp. , 4 61 F .3 d 6 39 , 6 43 (6 th C ir . 2 00 6) ); see also Stough v. M ayville Cmty. Sc h. , 138 F .3 d 6 12 , 6 14 (6 th C ir .1 99 8) (“ A d istri c t c ourt a bu se s it s d isc re tio n w he n it re lie s o n clearly
err oneous finding s of fa ct, when it improper ly applies the law , or uses an err oneous leg al standar d.”). II. P r ude nt ial ’s F indin g o f “Le ga l Int ox ic at ion ” To de te rm ine wh e the r P ru de nti a l a bu se d it s d isc re tio n in de nyingPla int if fs ’ c la im, we mus t deter mine whether

it was rea sonable for

Prudential to find that the decedent’ s death re sulted from his being “leg ally

intox icated.” A. Definition of L egal Intoxication Neither party disputes that Kentucky

law g overns the de termination of the standard for leg al int oxic a tio n. Ho we ve r, Pla int if fs argue that th e de fi nit ion fo r l e g a l intoxic a tio n a do pte d in Healthwise of Ky ., Ltd. v. Anglin, 956 S.W .2d 213, 217 (Ky . 1997), should g overn, w hile Def endant
argue s that the de fi nit ion of le g a l int oxic a tio n un de r the Ke ntu c ky mot or ve hic le statu te s hould g overn. Compare Ky . Rev. Stat. Ann. § 222.202(1) (“ [a] person is g uilty of alc ohol intox ication when he appea

rs in a public plac e manifestly under the influence of alc ohol to the deg ree that he mayThe intox ication exclusion in An gli n rea d as follows: “Tr eatment f or injuries sustained a s 2 a result of being under the influenc e of a lcohol (leg al intox ication as de fined by Kentucky

law) or the illeg al use of dr

ug s.” An gli n , 956 S.W .2d at 216. 6 endang er himself or

other pe rsons or prope rty , or unre asonably annoy persons in his vicinity ”) with Ky . Rev. Stat. Ann. § 189A.010(1)( a) ( “[a] person shall not operate or be in phy sical control of a motor vehicle a

ny wher e in this state . . [h] aving an alc ohol conce ntration of 0.08 or more . . .”). I n the Kentuc ky

Supreme Court ’s o n l y

pronounce ment reg ardingthe def inition of lega l intox ication, the cour

t held that an intox ication exclusion provision, which was s imilar in all releva nt respe cts to the exclusion provision at is sue, was ambig uous beca use there wer e seve ral de finitions
o f l e g a l i n t o x i c a t i o n t h a tc o u l d a p p l y. An gli n , 956 S.W .2d at 217. Be cause ambig uities in insurance 2 contra cts should be libera lly construed so a s to affor d cover ag e, se e W olf or d v . W olf or d , 662 S.W .2d 835, 838 (Ky . 1984), the court adopted the definition of l eg al intox ication under Ky . Rev. Stat. Ann. § 2 22 .2 02 (1 ), wh ic h ou tla ws a pp e ari ng in a pu

bli c pla c e manif

e stl y un de r t he inf lue nc e of a lc oh ol. An gli n , 956 S.W .2d at 217. I n An gli n , t h e in s u re d wa s i n j u re d wh i l e ra ci n g an o t h er v eh i cl e a ta h i gh
rate of sp e e d, and

his B AC wa s f

ound to b e 0. 21 pe rc e nt. Id. at 215. The e x clusion provision at issue here forbids “be ing le g ally intox icated” and does not ind ic a te wh ic h d e fi nit ion of le g a l in toxic a tio n und e r K e ntu c ky law s ho uld

a pp ly . T hu s, lik e in An gli n , th e te rm

is s ub je c t to mul tip le c on str

uc tio ns , a nd , th us , is a mbi gu ou s. F ur

the rm or e , in
a dd iti on to t he te rm be inga mbi g uo us on

its fa c e , a do pti ngthe sta nd ard un der th e mot or

ve hic le statute is even less appropr iate in t his case tha n in An gli n gi v en t h at M r. L o an wa s n o to p er at i n g a motor vehicle at the time of his fall.7

Def endant a rg ues that eve n if the Court wer e to deter mine that leg al intox icat i o n is an ambig uous term, this Court would be obliged to a cce pt Prudential’s interpre tation of the terms of the policy beca

use, under a

n abuse of

discretion standa

rd, a c ourt “must acc ept a plan a dminist rator’ s rational interpr etation of a plan even in the fac e of an equally rational interpre tation of fer ed by the participants.” Morgan v. SKF USA, I nc. , 385 F.3d 989, 992 ( 6th Cir. 2004) (interna l citation omitted). We ag ree that under a buse of discr etion revie w the Court is obligated to acc ept a plan administrat o r’ s ra t ional interpre tation of a plan. H oweve r, we disag ree that Prudential’s interpre tation is rational. Adopting a leg al definition specific ally intended to a pply to some one who is driving a motor vehicle is not rational as applied to someone who is in his own home and is not operating a

ny machiner y . There fore , the Court finds that the def inition of lega l intox ication that the Kentucky Supreme Court adopte d under similar c ircumstance s applies t o ex cl u s ion provision at issue. Given that the decedent was in his own hom e, not a public plac e, he c lear ly does not meet the test of being lega lly intox icated under Kentucky law. See Ky
. Rev. Stat. Ann. § 222.202(1) (“ [a] pe rs on is guil ty of a lc oh ol i nto xication when h e a pp e ars in a public place ”) ( emphasis adde d). F ur the rm or e , th e mot or

ve hic le statut e do e s n ot o utl aw c on du c tin g c ho re s ar ound the ho us e wh ile hav in g a B AC a bo ve 0. 08 pe rc e nt; it s imp ly ou tla ws driving w h il e h a v in g a B A C a b o v e 0.08 perc ent. Thus, eve n if it were rea sonable for Prudential to adopt the definition of intox ication under the mot or ve hic le statut e , M r. L oa

n’ s c on du c t w ou ld n ot f

a ll und e r the purv ie w of wh a t th e statut e pr oh ibi ts. Fin al l y , P ru d en t i al h as n o ts h o wn t h at M r. L o an ’s ac ci d en t“r es u l t [ ed ] fr o m ” h i s i n t o x ication,
a s th e pla n r e qu ir e s f

or Pr ud e nti a l to de ny

c ov e ra g e . After all , if a c la ima nt i s in toxic a te d w hil e standing on a porc h, the porch collapses, and he falls to his death, it cannot be said that his death has8

resulted from being leg ally intox icated. L ikewise, whe re Mr . L oan wa s not eng ag ing in pr ohibited conduct, Prudential cannot justifiably assume that Mr. L oan’s fall down the stair s and death by blunt forc e tra uma to the hea d resulted f rom intox ication. B. Pr udential ’s Reliance on Toxicology Report Prudential’s only

independe nt evidence of Mr. L oan’s intoxi cation wa s the tox icolog y repor t produc e d a f

te r h e w a s tr an s p o rte d to th e h o s p it a l. H o w e v e r , Pl a in ti f f s h a v e r a is e d a n umber of do ub ts a s to th e re lia

bil ity of toxic olo g y

re po rt s g e ne ra lly

and the re lia bil ity of the sp e c if

ic toxic olo g y

re po rt g e ne rate d in

thi s c a se . Co nc e rn ingtoxic ol og y re po rt s g e ne ra lly , Pl a int if fs c ite expert treatises de tailing the unr eliable natu re o f m oving f rom an e stimated BAC va lue to an assessment of the deg ree o f i ntox ication during the re levant per iod. See, e .g, 1 McCormick on Evidenc e § 205 (6 t h Ed.) (“ . . . one ca nnot assume that B AC inevitably is highe r at the time of a n
acc ident than it is afterw ards, at the time of testing , for the c oncentr ation rises af ter drinking , then dr op s. Extr a

po la tio ns ba se d o n d ir e c t mea sure me nts of B AC the re fo re se e m mo re pe ri lou s th an is g ener ally rec og nized. . . ”). Plaintiffs arg ue that while the in- house doctors pe rfor ming the r eview did not take these issues into consideration, any tox icolog y expert would have done so. Plaintiffs also point to the variety of factors that may aff ect BAC over time, including f ood intake, ty

pe and quantity of alc ohol, weig ht, sex , body fat pe rce ntag e, and ra t e o f ab sorption. See Ku pf e rs c hmi dt, G e r r y, Alcohol Absorption, Distri bution & Elimination (2004), available at
ww w. fo rc on .c a/le arn ing/a lc oh ol. htm l (last visited Mar. 17, 2010). Plaintiffs also claim t hat t here wer e a number of problems with the specific tox icolog y repor t at i s s u e. Acc ording to Plainti ffs, the blood test wa s perf ormed on ser

um, not whole blood as9

require d under K entucky law, and test re sults based on serum c an be up to 15% highe r. (App. at 82). I n addition, Plainti ffs a

rg ue that the pr esenc e of a varie ty of matters in Mr. L oan’s sy stem, including ketones fr om an Atkins diet, could have cre ated a false positive re port. (App. at 82-83). Ho we ve r, Dr . M a c B ri de , th e in- ho us e do c tor wh o r e v i e w e d

P l a i nt i f f s’ a pp e a l, d id n ot a dd

re ss the majority

of these issues; rather, he simply made the c onclusory

stat em en t t h at t h e excess of
e tha no l in Mr . L oa n’s s y ste m do c ume nte d in the toxic olo g y

re po rt ind ic a te d th a t Mr . L oa

n’ s “ fa ll
occur red c oncurr ently

with the prese nce of a BAC in excess of t he lega l limit .” (App. at 122). The only ref ere nce he made to the c laims Pl aintiffs’ raised on appea l was that the “ dece ased’ s spouse .

. . speculates that the ethanol e levation was a false positive.” (

Id. ) Ho we ve r, he did no t re fute thi s possibili ty

except to say t h at i t “l ac k s cre dibilit y ” without more infor mation. ( Id .) I n ma

kin g his
rec ommendations, Dr. Mac Br ide noted that “the ab o v e analy sis is based on g ener al medica l kn o w le d g e ” an d th a t “ [h e ] d o [e s ] n o t c la im to b e a F o r e n s ic to xic o lo g y s p e c ia list.” (Id. ) He indicated that “ it may

be worthwhile
. . . to consider having a n external fore nsic tox icolog ist review [t he re cord] . . .” (A

pp. at 121). Def endant a rg ues that Plaintiffs did not provide suffic ient proof in their a ppeal of the initial benef it determination that the tox icolog y repor t was flaw ed. Howe ver, Plaintiffs cited a number of g ener al re liability

problems with BA C tests conducted a s these we re a nd a number

of spec ific fa ctors prese nt in Mr. L oan’s ca s e t h at may have unr eliably

elevated his BAC. Dr . MacB ride did not addre ss any

of these in his re view. Wit hout the benef

it of a tox icolog y

expert’s ana ly sis, it is difficult to de termine whether the
re p o rt in qu e s ti o n w a s r e li a b le
. H o w e v e r , in a s mu c h a s Pr u d e n ti a l s im

p ly ig n o r e d th e ma

jo r ity of10

Plaintiffs’ attacks on the reliability of the toxi colog y repor

t and Prudential’s ow n doctor indicated that it might be worthwhile to consult a tox icolog y expert, it was unrea sonable unde r the circ umstances for Prudential to r ely on this toxi colog y repor t a lone, without the ben ef i t o f e x p ert analy sis, to determine that the de cede nt was leg ally intox icated. I I I . Pru d en ti a l ’s Re v i ew o f Pl a i n ti f f s ’ C l a i ms ERI SA “under score s the particula r importance of ac curate claims proc essing b y in s is ti n g that administrators provide a full and fair re view of c laim denials.” Glenn , 128 S. Ct . at 2350 (interna l citations omitt ed). Specifica lly , ERI SA require s plan admini strators to put claimants on notice of the re asons for the ir denial a nd to affor d claimants an opportunity to appea l the admini strator’s initial decision. Unde r ERI SA:

ever y employ ee be nefit plan shall-- (1) pr ovide ade quate notice in writing to a ny participa nt or bene ficiary wh o se cla im for be ne fi ts und e r t

he pla n h a s b e e n d e nie d, se tti ngfo rt h th e sp e c if

ic re a so ns fo r s uc h d e nia l, written in a manne r ca lculated to be unde rstood by the par ticipant, and (2) a ffor d a re asonable o p p o rtunity to any participa nt whose cla im for bene fits has been de nied for a

full and fa ir revie w by

the appr opriate na

med fiducia

ry of the decision deny

ing the claim. 29 U.S.C. § 1133. I n addition, the regulations analy zing ER I SA lay out the foll owing proce dure f or re viewing
an a pp e a l of an a dv e rs e be ne fi t de te rm inatio n: “ [ I ] n dec idi ngan a pp e a l of any a dv e rs e be ne fi t deter mination that is based in whole or in par t on a medical judgme nt
. . . [t he plan a dminist rator] sh a ll c on su lt w itha

he a lthc are pr of

e ssi on a l w ho ha s app ro pr ia te tr a ini ng and e xpe ri e nc e in t he fi e ld of medicine involved in the medical judg ment.” 29 § C.F.R. 2560.503-1( h)(iii).11

I n th ei r appeal of the a dverse benef its decision, Plainti ffs ra ised a number of issues
c on c e rn ingthe re lia

bil ity of the toxic olo g y re po rt , wh ic h Pr ud e nti a l’ s d oc tor

fa ile d to a dd

re ss i n h is analy sis. I n Dr. MacB ride’s r eport, he made c lear that his analy sis was based on g ener al medica l kn ow le dg e , th a t he wa s n ot a toxic olo g y

e xpe rt , a nd that it mig ht be wor th while f

or Pr ud e nti a l to
se e k th e op ini on

of a fo re ns ic toxic olo g ist . B y ig no ri ng thi s su g g e sti on , Pr

ud e nti a l f a ile d to “ c on su lt with a hea lth care profe ssional who has appr opriate tra ining a nd experience in the field of medicine involved in the medical judg ment.” 29 § C.F.R. 2560.503-1( h)(iii). Prudential argues t h at i t co n d ucted a full and fa ir revie w by

revie wing the claim a se cond time and consult ing with a second doctor. However , Prudential was on notice that the re liability of the toxic olo g y

re po rt wa s c e ntr a l to the de te rm inatio n o n a pp e a l and that their re viewing doctor wa s not in the positi on to ad d re s s P l ai n t i ffs’ claims. I n the intere st of rea ching an ac curate re sult, as ERI SA require s, Prudential should have c onsulted a tox icolog ist who co u l d h ave a ddresse d the i s s u e s t h a tP l a i n t i f

f s r a i s e d o na p p e a l
. T h i s i s n o t t o s a y t h a ta p l a na d m i n i s t r a t o r

m u s ta l w ays consult a spec ialist to provide a full and fair re view of a dverse benef its determinations. Howeve r, in a ca se such a s this, where Plaintiffs questioned the acc urac y and re liability

of t he tox icolog y

repor t in w ay s that only an expert could adequately addre ss, a tox icolog y expert was nec essar

y to provide a full and f

air re view. Fur thermore , Prudential did not seek the opinion of an outside expert who was not operating under Prudential’s conflict-of -intere st. Whil e the policy terms di d not require Prudential to hire an independe nt expert, this C ourt must weig h Prudential’s conf lict as a fa ctor in deter

mining whe ther the administrator a

bused its discretion. Glenn , 128 S. Ct . at 2348 (interna l c itations omitted). I n the ins tant c a se , Pr

ud e nti a l’ s in- ho us e do c tor ha d le ss inc e nti ve tha n a n in de pe nd e nt o uts ide do c tor to12

conduct a thoroug h and ac curate revie w of the rec ord and addre ss the arguments Plaintiffs r aised on
a pp e a l. IV. Disposition This panel unanimously

ag ree s that Prudential ab u s ed its discretion by denying a ccide ntal death be nefits to Plaintiffs on the basis that the dece dent was leg ally intox icated without conducting a full and f

air re view. Howe ver, this pane l disag ree s on the appropr iate dis position. J udg es Guy and Whit e would vac ate the district c ourt’s orde r and rema nd to pe rmit the parties to be hea rd and the dis tr ic t ju dg e de c ide in t

he fi rs t in sta

nc e wh e the r P la int if

fs are no w e nti tle d to a

jud g me nt i n th e ir favor . Be cause they

constitute a majority , that is the disposit ion of the Court. Howeve r, this resolution is inappropriate a nd ill-founded. Judges Guy and White have po int e d to no fa c tua l di sp ute s th a t r e ma in i n th e c a se . T he a dmi nis tr a tiv e re c or d is c omp le te , a ll f a c ts neede d to decide the case are rea dily appar ent, and ther e is no additional evidenc e to be de rived. B e c a us e the a pp ro pr ia te ou tc ome –a

n aw ard of be ne fi ts und e r t he po lic y –is dis c e rn ibl e on

the ba sis of thi s c om

p l e t e r e c o r d , r e m an d i n g t h e c a s e t o a l l o w t h e p art i e s t o b e h e ar d a g a i n i s b oth proce durally

inappropriate and a

n improper wa ste of judicial re source s. Se e Sh e lby Cou nty He alt h Care Corp. v. Majestic Star Casino , 5 8 1 F
. 3 d 3 5 5 , 3 7 4 ( 6 th Ci r . 2 0 0 9 ) ( f in d in g rema nd to be an inap p ro p riate r emedy

when “ there are no additional fac ts to develop or other finding s that . . . the plan administrator ne eds t o m ak e” ). Ac cording ly , Iwould vacate the district cour t’s order and
re mand wi th i ns tr

uc tio ns to the dis tr ic t c ourt to o rd e r P ru de nti a l to awa rd Pla int if fs the a pp ro pr ia te b e n e f i t s u n d e r t h e p o l i c y.13 CO NC LU SION This panel unanimou s l y agre es that Prudential abuse d its discretion by denying a ccide ntal death be nefits to Plaintiffs on the basis that the dece dent was leg ally intox icated w ithout conducting a full and f

air re view. As a

result, we VA CA TE the dis tr ic t c ourt ’s ord er a nd a ma jor ity of thi s Court REMAND S to pe rmit the parties to be hea rd and the district judge decide in the first instance whether Plaintiffs are now

entitled to a judg ment in their favor
.14

GU Y, Jr., c oncurring in p art. I ag ree that the summary judgme nt g rante d to the defe ndant sh ou ld b e re ve rs e d. Ho we ve r, it i s n ot c le ar t o me th at th e case is n owin a po sture that make s it
a pp ro pr ia te fo r u s to or de r t he dis tr ic t ju dg e to e nte r s umm ary jud g me nt fo r t

he pla int if

f. Iwo uld
rema nd and let the pa

rties b e h ear d and the district judg e dec ide in the first instance whether the plaintiff is now entitled to a judg ment in her fa vor.Prudential relies on the exclusion t o deny cover ag e, and doe s n o t appear to ar g ue that the 1 loss does not otherwise satisfy the conditions for c overa g e. I do not rea d Dr. MacB ride’s statement that “it may be wor thwhile, if war

rante d, to consider 2 having an external for ensic tox i co l o gy s p ecialist review to bolster what Dr. Kowa lski and Ihave alre ady conclude d” as the doctor’s a dmission t hat he lac ked suff icient expertise. R at h er, the comment was ma de to the cla ims department in the conte x t of an observation that the claimant wif e wo rk s f or a natio na l f ir m th a t do e s d ia g no sti c la

bw or k. I n an y e ve nt, thi s c omm e nt i s n ot c ru c ia l to the eva luation of the cla imants’ case
. 15 H E L ENE N. WHITE , Circuit Judge, concurr ing. Under the policy , the claimants a re 1

e nti tle d to be ne fi ts f

or los s d ue to a c c ide nta l inju ry un le ss t he los s r e su lte d f

ro m be ing“ le g a lly intox icated.” A re view of the administrative re cord r evea ls that Prudential found that the exclusion
a pp lie s b a se d o n th e sin g le fa c t th a t th e ins ur e d ha d a pla sma a lc oh ol le ve l of 178 mg /dl wh e n h is blood was dra

wn a little over a

n hour af ter the f all. Iag ree with the majority

that Prudential’s denia l was not the produc t of a full and fa ir revie w. Whil e the in-house medical r eviewe rs did make a djustments for the fac t that the hos pital’s test was pe rf or me d o n p la sma , r a the r tha n who le blo od , the ma

jor ity c or re c tly ob se rv e s th a t th e e xpe rt s d id not fully and fa irly

consider the claimants’ other objections to the tox icolog y report an d the inf e re nc e s d ra wn the re fr om. 2 The de n i al was based on the assumptions that the test was not af fec ted by the insured’ s consumption of cold medicine, or Clonazepam, or the ketone s produce d by Atkins’ di et , and the conclusion, apparently not based on expert analy sis, that the blood alcohol level of the blood drawn 1 1/4 hou rs a ft e r the fa ll ac c ur a te ly re fl e c te d the ins ur e d’ s bloo d a lc oh ol l e ve l a t th e tim e of the fa ll. Fur ther, the a dminist rative r ecor d reve als no ana ly sis of the timing of the insured’s consumption of the alcohol or

his siz e and w eig ht, and no ana ly sis of the likely eff ects of a par

ticular blood alc ohol level on par

ticular activities. I nstead, the medical eva luations were based on g ener al statements and16

conclusi o n s am o unting to an a ssumption t hat bec ause the fall occ urre d when the insure d had a particula r blood a lcohol level (base d on the later test), the fa ll must have r esulted fr om intox ication. Additionally , the admi n i s t ra t ive re cord r evea ls that no consideration was g iven to the insured’ s wife’ s acc ount of the insured’ s behavior pr ior to the fall, and no attempt was made to see w hether
su c h c la ims c ou ld b e ve ri fi e d. Whil e the ins ur e d’ s w if e is c e rt a inl y an int e re ste d pa rt y a s a c la ima nt, it does not follow that her a ccount c an properl y b e d i s missed without any consideration or investigation. Thus , I a g re e tha t Pr ud e nti a l a bu se d it s d isc re tio n a

nd a c te d a rbi tr ari ly and c a pr ic iou sly in denying this cla im. I would rema nd, for the r easons state d in J udg e Guy ’s conc urre nce.