UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF MICHIGAN

SOUTHERN DIVISION

 

LEO WEATHERS,

Plaintiff,

v. Case No. 08-14788

MUTUAL OF OMAHA INSURANCE COMPANY,

Defendant.

/

OPINION AND ORDER GRANTING DEFENDANT’S MOTION FOR JUDGMENT, AND

DENYING PLAINTIFF’S MOTION FOR JUDGMENT

 Pending before the court are cross-motions for judgment, filed by Plaintiff Leo

Weathers on June 15, 2009, and filed by Defendant Mutual of Omaha Insurance

Company on June 30, 2009. Both motions seek final judgment on Plaintiff’s claim for

accidental death benefits under 29 U.S.C § 1132(a)(1)(B). Having reviewed the briefs,

the court concludes a hearing is unnecessary. See E.D. Mich. LR 7.1(e)(2). For the

reasons stated below, the court will grant Defendant’s motion and deny Plaintiff’s

motion. 

I. BACKGROUND 

Plaintiff initiated this case by filing a complaint on November 14, 2008. Plaintiff’s

complaint seeks accidental death benefits under an accidental death and

dismemberment (“ADD”) insurance plan maintained by his employer, Ford Motor

Company (“Ford”). The ADD plan is underwritten by Defendant and is governed by the

Employee Retirement Income Security Act (“ERISA”). Benefits are available to insured

Ford employees in certain cases of physical injury and death. Benefits are funded by

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Defendant, who also administers claims under the policy and has authority to make final

determinations on eligibility for benefits. 

Defendant issued a master insurance policy (“the Policy”) to Ford providing

Ford’s employees with the option of enrolling as insureds under the Policy. (AR 46.) 

The Policy contained in the administrative record became effective in 2004. (AR 46.) 

The Policy provides benefits in certain cases of accidental death or physical injury. (AR

33.) When a Ford employee enrolled in the Policy, Defendant issued each enrollee a

certificate of insurance. (AR 47.) The insurance certificate (the “Certificate”) contained

in the administrative record was issued to Plaintiff under the 2004 Policy. (AR 33.) The

Certificate states that it replaces “any and all insurance certificates and riders that may

have been issued previously to the insured under the previous group accident master

policy.” (Id.) The record does not contain any previous policies or certificates issued to

Ford or Plaintiff, and the parties have not pointed to anything (and the court has not

found anything) in the record which explicitly ties the 2004 Policy and Certificate to

specific, previous policies and certificates issued by Defendant to Ford or Ford

employees. 

Under the Policy, insureds have the option to enroll for family coverage. (AR 34.) 

Under the family coverage option an enrollee’s dependents are covered as “insured

dependents.” (Id.) The Certificate defines dependents:

“Dependent” shall mean: 

(1) the spouse of the Insured; and

(2) any unmarried Dependent Children:

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(a) of the insured by birth, legal adoption or legal

guardianship, while such child legally resides with and

is dependent upon the Insured; or

(b) of the Insured’s spouse while such child is in the

custody of and dependent upon the Insured’s spouse

and is residing and a member of the Insured’s

household; or

(c) as defined in (a) or (b) above who does not reside

with the Insured but is the Insured’s legal

responsibility for the provision of health care (for

purposes of this insurance “legal responsibility” shall

mean only that responsibility assigned to the Insured

by a court of competent jurisdiction); or

(d) who resides with and is related by blood or

marriage to the Insured for whom the Insured

provides principal support as defined by the Internal

Revenue Code of the United States, and who was

reported as a Dependent on the Insured’s most recent

income tax return or who qualifies in the current year

for dependency tax status. 

(Id.) Where spouses are employees of Ford and eligible to enroll under the Policy, “in

no event can both apply for family coverage.” (Id.) Moreover, pursuant to the

Certificate, an individual can be insured under only one certificate at any given time. 

(AR 41.) Apparently, a policy booklet distributed to Ford employees stated that no

person can be insured or eligible for dependent life insurance as the dependent of more

than one Ford employee. (AR 12.) The statement was intended to describe the ADD

plan, but erroneously referred to a life insurance plan. (AR 12.) The policy booklet

does not appear in the record. 

The Policy also places a limit on Defendant’s ability to contest the validity of the

Policy—after the Policy has been in force for two years, Defendant cannot contest the

Policy’s validity except for nonpayment of the Policy’s premium. (AR 47.)

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Leo James-Antoine Weathers (“L.J. Weathers”) was born to Plaintiff and his exspouse, now known as LoTonya Burston, in 1987. (AR 363.) Although the record

indicates that Plaintiff was divorced from Burston in 1997, the parties do not cite

anything on the record stating when Burston and Plaintiff married. The divorce court

granted joint legal custody to both Plaintiff and Burston, but it granted Burston “primary

physical possession.” (AR 345.) The divorce court also ordered Burston and Plaintiff to

“maintain any health care coverage that is available at a reasonable cost, as a benefit of

employment, for [L.J. Weathers].” The divorce court also ordered that Plaintiff “shall pay

49% of any and all uninsured health care expenses incurred by [L.J. Weathers].” (AR

346.) 

Plaintiff began working for Ford around 1986. (AR 119.) He first applied for

family coverage under an ADD plan beginning in 1995. (AR 16.) No master policy or

certificate for the 1995 policy for which Plaintiff applied appears in the record. Burston

began working for Ford in 1989. (Id.) Burston first applied for family coverage under an

ADD plan in 1994. (Id.) No master policy or certificate for the 1994 policy for which

Burston applied appears in the record.

Plaintiff never covered L.J. Weathers’s health care through his benefits with Ford. 

(AR 250.) The record is equivocal on whether Burston carried health insurance for L.J.

Weathers through her employer, Ford. Statements by Plaintiff and Burston indicate that

they had an informal agreement obliging Burston to provide L.J. Weathers’s insurance

through Ford. (AR 5, 6, 7.) But Ford indicated that Burston had no dependents on her

health care contract since August 2004. (AR 250.) 

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On February 19, 2006, L.J. Weathers was shot in the leg with a shotgun and

died. (AR 124.) In 2006, both Plaintiff and Burston applied for accidental death

benefits, due under the Policy issued by Defendant, to cover L.J. Weathers’s death. 

(AR 16.) The disposition of the case was delayed significantly because Defendant

required a determination of whether L.J. Weathers’s death qualified under the ADD

plan. (AR 89.) Finally, in Spring 2008, Defendant denied Plaintiff’s claim under the

ADD plan, reasoning that L.J. Burston was not Plaintiff’s dependent as defined by the

Certificate. Defendant granted Burston’s claim. (AR 58-60, 307.) 

The record contains conflicting evidence on whether L.J. Weathers resided with

both Plaintiff and Burston or only with Burston before he died. Some portions of the

record indicate that L.J. Weathers split his time between Plaintiff’s residence and

Burston’s residence. (AR 6, 13, 31.) On the other hand, the record indicates that

Burston stated that L.J. Weathers had always lived with her and that she had no

knowledge of whether L.J. Weathers ever spent a night at Plaintiff’s home. (AR 268.) 

Further, L.J. Weathers’s driver’s license, school records, insurance card, and credit card

statement all state Burston’s address as his home address. (AR 363-64, 367-68.) 

Plaintiff concedes that L.J. Weathers did not reside with him. (Pl.’s Mot. Br. 4.) 

II. STANDARD

In Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609 (6th Cir. 1998), the Sixth

Circuit set forth “Suggested Guidelines” to adjudicate claims based on improper denials

of ERISA benefits. A district court’s review of a plan administer’s determination should

normally be confined to the evidence that was in the record before the plan

administrator. Id. at 618 (citing Rowan v. Unum Life Ins. Co., 119 F.3d 433, 437 (6th

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Cir. 1997)); Barone v. Unum Life Ins. Co. of Am., 186 F. Supp. 2d 777, 779 (E.D. Mich.

2002). The “Suggested Guidelines” in Wilkins direct the district court to review a plan

administrator’s decision based solely on the administrative record and render findings of

fact and conclusions of law. Wilkins, 150 F.3d at 618; Barone,186 F. Supp. 2d at 779. 

The district court reviews a denial of benefits challenged under 29 U.S.C. §

1132(a)(1)(B) de novo “unless the benefit plan gives the administrator or fiduciary

discretionary authority to determine eligibility for benefits or to construe the terms of the

plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Marks, 342

F.3d at 456. “If a plan affords such discretion to an administrator or fiduciary, we review

the denial of benefits only to determine if it was ‘arbitrary and capricious.’” Marks, 342

F.3d at 456 (citing Miller v. Metro. Life Ins. Co., 925 F.2d 979, 983 (6th Cir. 1991)). In

this case, the court has already concluded that it will review the administrator’s decision

under the “arbitrary and capricious” standard. (See 6/9/2009 Order 1.)

A district court will uphold the determination of an administrator under the

arbitrary and capricious standard if it is “rational in light of the plan’s provisions.” Marks,

342 F.3d at 457 (quoting Borda v. Hardy, Lewis, Pollard & Page, P.C., 138 F.3d 1062,

1066 (6th Cir. 1998)). Where, as here, an entity both funds and administers the plan at

issue, “there is an actual, readily apparent conflict.” Killian v. Healthsource Provident

Admin., Inc., 152 F.3d 514, 521 (6th Cir. 1998). The Sixth Circuit has stated, that in

such cases, the abuse of discretion or arbitrary and capricious standard still applies “but

application of the standard should be shaped by the circumstances of [any] inherent

conflict of interest.” Borda, 138 F.3d at 1069; see also Univ. Hosp. of Cleveland v.

Emerson Elec. Co., 202 F.3d 839, 846 (6th Cir. 2000).

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III. DISCUSSION 

Having reviewed the parties’ briefs and the administrative record, the court

concludes that, in light of the deferential review afforded to Defendant, Defendant’s

decision to deny Plaintiff’s benefits was not arbitrary and capricious.

A. L.J. Weathers as a Dependent under the Certificate

Plaintiff argues that he is eligible to receive accidental death benefits because

L.J. Weathers is a dependant under the Certificate’s third definition of a child

dependent; i.e., L.J. Weathers is a dependent because he is Plaintiff’s child “who does

not reside with the [Plaintiff] but is the [Plaintiff’s] legal responsibility for the provision of

health care.” (See AR 58.) Plaintiff reasons that he had a legal responsibility to provide

health care because the divorce court ordered him to “maintain any health care

coverage that is available at a reasonable cost, as a benefit of employment, for [L.J.

Weathers].” (AR 346.) Defendant responds that this provision of the Certificate cannot

apply because Plaintiff was not actually providing health care coverage for L.J.

Weathers. Specifically, Defendant intimates that the Certificate’s third definition does

not apply because Plaintiff was either not required by law to provide health coverage

(e.g., the cost was not reasonable), or he was failing to fulfill the legal obligation. 

According to Defendant’s reasoning, in either case, the absence of coverage means

that L.J. Weathers was not a dependent under the health-care responsibility definition. 

To decide whether Defendant’s reasoning rises above the arbitrary and capricious

threshold, the court must interpret the Certificate. 

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“When interpreting ERISA plans, federal courts apply ‘general rules’ of

contract law as part of the federal common law.” Cassidy v. Akzo Nobel

Salt, Inc., 308 F.3d 613, 615 (6th Cir.2002). As such, “courts interpret

ERISA plan provisions according to their plain meaning, in an ordinary and

popular sense,” giving effect to any unambiguous terms. Id. at 617-18

(internal quotation marks and citations omitted).

Smith v. Bayer Corp. Long Term Disability Plan, 275 F. App’x 495, 512 (6th Cir. 2008).

The court is not convinced that Defendant’s argument passes muster. First, the

Certificate’s language mentions nothing about complying with the legal responsibility to

provide health care. Instead, the plain meaning suggests that if a legal responsibility to

provide health care exists, then the child is a dependent regardless of the parent’s

fulfillment of that responsibility. Perhaps, Defendant’s argument is that fulfilling the

responsibility is an implied term of the Certificate, but Defendant points to nothing on the

record suggesting that the parties to the ADD plan would have intended such a term. 

Defendant’s argument also suggests that there was no legal responsibility in this case

because the divorce court’s requirements for imposing a responsibility were not present. 

For example, the record yields some support for the conclusion that the cost of the

health care coverage was unreasonable. Plaintiff stated that he had an agreement with

Burston that she would provide health care and he would provide life insurance. If

Plaintiff knew, or had good reason to think, that Burston was providing health care for

L.J. Weathers then any coverage he would have purchased might well have been

completely duplicative. Since the benefit of purchasing duplicative coverage is a nullity,

paying anything for it would be unreasonable.

But regardless of whether Plaintiff had a legal responsibility to provide health

care coverage under the divorce decree, L.J. Weathers qualified as a dependent

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because Plaintiff was required to provide health care under a different provision in the

divorce decree. Under the divorce decree Plaintiff was required to “pay 49% of any and

all uninsured health care expenses incurred by [L.J. Weathers].” And the Certificate

requires a “legal responsibility for the provision of health care.” The plain meaning of

the phrase “provision of health care” includes but is broader than the provision of healthcare insurance. Paying for a percentage of uninsured health care expenses, as was

required by the divorce court, is the provision of health care. And, as such, Plaintiff had

a legal responsibility to provide health care for L.J. Weathers, who was therefore a

dependent under the Certificate. Because the Certificate’s plain meaning would include

L.J. Weathers as a dependent, it would be arbitrary and capricious to reject Plaintiff’s

claim on this basis.

B. Multiple Insureds Under One Certificate 

Defendant also argues that Plaintiff is not entitled to recover accidental death

benefits because the Certificate states that two spouses who are employees cannot

both apply for family coverage. Defendant reasons that since Plaintiff and Burston were

married when they originally applied for an ADD plan, and since Plaintiff’s application

was after Burston’s, Plaintiff’s family coverage was void. At first glance, there are two

potential issues with this reasoning. First, the parties do not cite anything on the record

which explicitly states when Plaintiff and Burston were married. So, there is some

question as to whether Plaintiff and Burston were actually spouses in 1994 and 1995

when they applied for coverage. But, in their briefing, both parties assume or state that

Plaintiff and Burston were married in 1994 and 1995. (Pl.’s Rep. Br. 1; Def.’s Resp. Br.

6.) The court is inclined to follow their lead on this point—the record strongly implies

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that Plaintiff and Burston were married when they applied for the ADD family coverage. 

(AR 16, 34, 343-49.) Second, the Certificate that controls the outcome of this case was

issued in 2004—after Plaintiff was divorced from Burston. Nothing in the record

explicitly ties the 2004 Certificate to the 1994 and 1995 certificates in place when

Plaintiff and Burston applied for ADD family coverage. But, again, the parties assume

that the 2004 Certificate is a continuation of those in place in 1994 and 1995, and that

the family coverage clause in the 2004 Certificate applies to Plaintiff’s original

application. (Pl.’s Rep. Br. 1; Def.’s Resp. Br. 6.) Moreover, the same may be inferred

from the administrative record. (AR 16, 22-23, 219.) Given the Certificate’s clear

language prohibiting two, married Ford employees from claiming family coverage, it was

not arbitrary and capricious to conclude that Plaintiff could not claim the ADD benefit

because both he and Burston applied for family coverage. 

Moreover, the Certificate contains another clause, cited by neither Plaintiff nor

Defendant, that prohibits duplicative coverage in certain cases: “A person may be

insured under only one certificate at any one time under the policy.” (AR 41.) 

Accordingly, if an insured dependent is a person “insured under [a] certificate” then the

dependent may be covered by only one certificate. The plain meaning of this statement

has the effect of preventing a dependent from being insured under the ADD plan by

more than one employee since each employee receives a certificate. The question is

therefore whether the phrase “person[s] . . . insured under [a] certificate” includes

insured dependents or only the primary insureds, i.e., the enrolled employee. Insured

dependents are defined as the “Insured’s dependents” who are “insured.” (AR 33.) 

Accordingly, the plain language of the Certificate establishes that insured dependents

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 If only in passing, the court deems the Policy’s incontestibility clause worth

mentioning, given that it was not cited by the parties. The clause states that Defendant

“will not contest the validity of the policy after it has been in force [for two] years,” (AR

47), and the court views this as referring to contesting the master policy with Ford, not

the validity of coverage with individual insureds. An exception to the incontestability

clause is contesting “the policy’s” validity based on failure to pay “the premium”; the

premium is the sum of individual premiums. Accordingly, the incontestability clause

must refer to Defendant’s ability to challenge the master Policy with Ford, rather than an

individual’s coverage. 

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are part of the larger class of persons “insured under a certificate.” Thus, a reasonable

interpretation of the Certificate is that any given insured dependent can be covered by

only one certificate and, therefore, can be claimed as an ADD dependent by only one

employee. This analysis leaves open one question: whether L.J. Weathers was

properly considered insured under Burston’s or Plaintiff’s certificate. The Certificate and

Policy are silent on which certificate controls when an insured dependent is insured

under multiple certificates. Given this ambiguity, the contract should be interpreted to

render it reasonable. See, e.g., 11 Williston on Contracts § 32:11 (4th ed.). It is

immediately apparent that the only reasonable interpretation of the Policy and

Certificate is that an earlier certificate will be effective over a later certificate. Otherwise,

a later certificate could render a previous, validly-issued certificate invalid. Burston was

the first to insure L.J. Weathers as an insured Dependent. It is true that the Certificate

at issue was not the one under which Plaintiff applied in 1995, but one may infer from

the record that Burston and Plaintiff continuously covered L.J. Weathers. Assuming

this, it is reasonable to confer a first-in-time status on Burston’s certificate. The court

will therefore find that it is not arbitrary and capricious to find that L.J. Weathers could

not be covered under Plaintiff’s Certificate.1

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IV. CONCLUSION 

Since L.J. Weathers could not be covered under both Plaintiff’s and Burston’s

certificates, Defendant’s denial of Plaintiff’s benefits was not arbitrary and capricious.

IT IS ORDERED that Defendant’s motion for judgment [Dkt. # 21] is GRANTED.

IT IS FURTHER ORDERED that Plaintiff’s motion for judgment [Dkt. # 17] is

DENIED.

 S/Robert H. Cleland 

ROBERT H. CLELAND

UNITED STATES DISTRICT JUDGE

Dated: October 28, 2009

I hereby certify that a copy of the foregoing document was mailed to counsel of record

on this date, October 28, 2009, by electronic and/or ordinary mail.

 S/Felicia Moses for Lisa G. Wagner 

Case Manager and Deputy Clerk

(313) 234-5522

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