Court Opinion

ID: 4854160
Source: CourtListenerOpinion
Date Created: 2021-08-24 16:03:28.216285+00
Date Added: 2024-06-11T08:11:47.722113
License: Public Domain

United States Court of Appeals
                            For the Eighth Circuit
                        ___________________________

                                No. 20-1694
                        ___________________________

                               Gary L. Williams

                                    Plaintiff - Appellant

                                       v.

                   Unum Life Insurance Company of America

                                   Defendant - Appellee
                                ____________

                    Appeal from United States District Court
               for the Western District of Missouri - Kansas City
                                ____________

                         Submitted: February 16, 2021
                            Filed: August 24, 2021
                                ____________

Before SMITH, Chief Judge, ARNOLD and STRAS, Circuit Judges.
                              ____________

STRAS, Circuit Judge.

       Does an accidental-death-and-dismemberment insurance policy qualify as “a
health plan” under Maine law? Me. Rev. Stat. Ann. tit. 24-A, § 4303. The answer
is no, which means that Unum Life Insurance Company’s decision to deny benefits
is subject to a deferential abuse-of-discretion standard of review. Like the district
court, 1 we conclude that there was no abuse of discretion.

                                          I.

      Kathy Williams died after she fell down a flight of stairs in her Missouri home.
According to the death certificate, the cause was an “intracranial hemorrhage” and
the manner in which it occurred was an “accident.” (Capitalization omitted). As it
turned out, Kathy’s blood-alcohol content was 0.337—more than four times the legal
driving limit in Missouri. See Mo. Rev. Stat. § 577.012.1(1).

       Several weeks later, her husband Gary submitted a claim to Unum for benefits
under an accidental-death-and-dismemberment policy. After investigating the
claim, Unum denied benefits under the policy’s intoxication exclusion. The denial
letter pointed out that the “accidental loss[]” in Kathy’s case was “caused by,
contributed to by, or result[ed] from . . . being intoxicated.” J.A. 175 (quoting the
exclusion). Gary’s administrative appeal met a similar fate, with the company
writing that “available information support[ed] that [Kathy’s] fall (which caused her
death) was caused by, contributed to by, or result[ed] from her level of intoxication.”
J.A. 877.

       Having exhausted the policy’s administrative process without success, Gary
sued Unum in federal court. See 29 U.S.C. § 1132(a)(1)(B). The district court
granted summary judgment to the company on the ground that it had not abused its
discretion in denying benefits.

      1
      The Honorable Fernando J. Gaitan, Jr., United States District Judge for the
Western District of Missouri.

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                                           II.

      We review the district court’s decision to grant summary judgment de novo.
Tonelli v. United States, 60 F.3d 492, 494 (8th Cir. 1995). “Summary judgment
[was] appropriate [if] the evidence, viewed in [the] light most favorable to [Gary],
shows no genuine issue of material fact exists and [Unum was] entitled to judgment
as a matter of law.” Phillips v. Mathews, 547 F.3d 905, 909 (8th Cir. 2008)
(quotation marks omitted).

      This case presents two issues. The first is whether we owe any deference to
Unum’s decision. The second is whether the decision survives. On both points, we
agree with the district court, which applied an abuse-of-discretion standard to
conclude that Unum did not overstep when it denied benefits. 2

                                           A.

      Ordinarily, when an accidental-death-and-dismemberment policy “give[s] the
plan administrator . . . discretionary authority to determine eligibility for benefits or
to construe [its] terms,” we review the “decision . . . under an abuse-of-discretion
standard.” Nichols v. Unicare Life & Health Ins. Co., 739 F.3d 1176, 1181 (8th Cir.
2014). Under this standard, we will uphold the decision if it is supported by
substantial evidence. See McClelland v. Life Ins. Co. of N. Am., 679 F.3d 755, 759
(8th Cir. 2012).

       Even though the policy in this case grants discretion, Gary’s position is that
the rule is different in Maine, which has a statute forbidding “health plan[s]” from
conferring “absolute discretion” on plan administrators. Me. Rev. Stat. Ann. tit. 24-

      2
         We decline to address Gary’s argument, raised now for the first time on
appeal, that we should ignore the intoxication exclusion because there is no mention
of it in the policy’s summary-plan description. See 29 U.S.C. § 1022(b); Oil & Gas
Transfer L.L.C. v. Karr, 928 F.3d 1120, 1123 n.2 (8th Cir. 2019) (refusing to
consider an argument initially raised on appeal).

                                          -3-
A, § 4303, 4303(11)(A). With discretionary clauses “[un]enforce[able],” id.
§ 4303(11)(B), Gary’s view is that de-novo review applies instead, see Firestone
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) (requiring de-novo review if
there is no applicable discretion-conferring clause).

       For Gary’s theory to work, an accidental-death-and-dismemberment policy
must be “a health plan.” Me. Rev. Stat. Ann. tit. 24-A, § 4303. Under Maine law,
health plans “provide[] for the financing or delivery of health care services to persons
enrolled in the plan, other than a plan that provides only accidental injury . . .
coverage,” or are “subject to the requirements of the federal Affordable Care Act.”
Me. Rev. Stat. Ann. tit. 24-A, § 4301-A(7); see Termorshuizen v. Spurwink Servs.,
Inc., 208 A.3d 415, 419 (Me. 2019) (asking first whether there is “a clear statutory
definition”).

       The first part of the definition is of no help to Gary because the policy does
not “provide[] for the financing or delivery of health care services.” Me. Rev. Stat.
Ann. tit. 24-A, § 4301-A(7). To be sure, it does provide limited physical-therapy
benefits, which are typically considered health-care services. See The American
Heritage Dictionary of the English Language 810 (5th ed. 2016) (defining “health
care” as “[t]he prevention, treatment, and management of illness and the
preservation of mental and physical well-being”). But it does so only in the event
of an accident, which does not count under the statute. See Me. Rev. Stat. Ann. tit.
24-A, § 4301-A(7) (excluding “plan[s] that provide[] only accidental injury . . .
coverage”). As for the remaining benefits, which consist of cash payouts, none even
arguably “provides for the financing or delivery of health care services.”

        Nor is the policy “subject to the requirements of the federal Affordable Care
Act,” Me. Rev. Stat. Ann. tit. 24-A, § 4301-A(7), which contains a long list of
“excepted benefits,” Public Health Service Act § 2791(c), 42 U.S.C. § 300gg-91(c);
see also Patient Protection and Affordable Care Act § 5000A(f)(3)(A), 26 U.S.C.
§ 5000A(f)(3)(A) (excluding “benefits . . . described in paragraph (1) of subsection
(c) of section 2791 of the Public Health Service Act” from the definition of “minimal

                                          -4-
essential coverage”). Among them is the type of insurance we have here:
“[c]overage only for accident[s].” Public Health Service Act § 2791(c)(1)(A), 42
U.S.C. § 300gg-91(c)(1)(A); see also Patient Protection and Affordable Care Act
§§ 1301–1302, 42 U.S.C. §§ 18021–18022 (defining “essential health benefits
package” and “health plan,” with reference to section 2791 of the Public Health
Service Act).

      To summarize, Maine’s ban on discretionary clauses singles out “health
plan[s].” 3 Me. Rev. Stat. Ann. tit. 24-A, § 4303. With Unum’s policy covering
accidental death and dismemberment, rather than the delivery or financing of health-
care services, the discretionary clause kicks in and we review the plan
administrator’s decision for an abuse of discretion. See Nichols, 739 F.3d at 1181.

                                         B.

       Given that there was plenty of evidence that Kathy was intoxicated when she
fell down the stairs, Unum did not abuse its discretion by denying benefits under the
policy’s intoxication exclusion. From a blood-alcohol level of 0.337 to the opinions
of multiple medical experts that a level so high could have led to incoordination and
an inability to stand or walk safely, substantial evidence supported Unum’s
conclusion that intoxication “contributed to” her fall.

       The policy itself did not require anything more. Intoxication can “contribute
to” a loss without being the only reason it happened. See American Heritage
Dictionary, supra, at 399 (defining “contribute” as “help[ing] [to] bring about”); see
also Kutten v. Sun Life Assur. Co. of Canada, 759 F.3d 942, 945 (8th Cir. 2014)
(noting that “the dictionary definition of [a] word” may be considered in
circumstances like these (quotation marks omitted)). Even if other factors played a
role in Kathy’s death, in other words, Unum still “reasonabl[y]” concluded that

      3
       There is no question of ERISA preemption here because Maine’s law
“regulates insurance.” 29 U.S.C. § 1144(b)(2)(A).

                                         -5-
Kathy’s extreme intoxication “contributed to” the fatal injuries she suffered. See
Johnson v. U.S. Bancorp Broad-Based Change In Control Severance Pay Program,
424 F.3d 734, 738 (8th Cir. 2005) (explaining that a “plan administrator’s
interpretation” of the policy must be “reasonable”).

                                       III.

      We accordingly affirm the judgment of the district court.
                     ______________________________

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