Court Opinion

ID: 4174054
Source: CourtListenerOpinion
Date Created: 2017-06-02 15:04:29.664325+00
Date Added: 2024-06-11T14:38:54.704072
License: Public Domain

Case: 16-15900   Date Filed: 06/02/2017   Page: 1 of 14

                                                         [DO NOT PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                     FOR THE ELEVENTH CIRCUIT
                       ________________________

                             No. 16-15900
                         Non-Argument Calendar
                       ________________________

                   D.C. Docket No. 1:15-cv-00628-WSD

STEVEN D. PRELUTSKY,

                                                               Plaintiff-Appellee,

                                  versus

GREATER GEORGIA LIFE INSURANCE COMPANY,

                                                        Defendant-Appellant.

                       ________________________

                Appeal from the United States District Court
                   for the Northern District of Georgia
                      ________________________

                              (June 2, 2017)

Before MARTIN, JORDAN, and ROSENBAUM, Circuit Judges.

PER CURIAM:
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      Greater Georgia Life Insurance Company (“GGL”) appeals the district

court’s grant of summary judgment to Steven Prelutsky on Prelutsky’s claim under

the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et

seq., that GGL wrongfully denied him benefits. After careful review, we reverse.

                                         I.

      Steven Prelutsky was a partner at the law firm Hall, Booth, Smith, PC and

participated in the firm’s long-term disability benefits plan (“the Plan”). The Plan

is provided through a group insurance policy insured by GGL. GGL serves as both

the Plan’s administrator of claims and the payor of benefits. The Plan vests GGL

with discretionary authority to interpret the Plan’s terms and determine whether a

claim should be paid. The Plan excludes from coverage any disability “caused by,

resulting from, or related to” intoxication (“the Intoxication Exclusion”). The

Plan’s Intoxication Exclusion says:

      The Policy does not cover any disabilities or loss caused by, resulting
      from, or related to any of the following . . .

      Any accident, Injury or Illness caused by, resulting from, or related to
      Your being under the voluntary influence of any drug, narcotic,
      intoxicant or chemical, unless administered by or taken according to
      the advice of a Physician.

      In March 2014, while on a ski vacation in Aspen, Colorado, Prelutsky fell

down a flight of twenty stairs in the home where he was staying. There were no

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witnesses to the fall. At some point after the fall, Prelutsky’s son found him. 1

When paramedics arrived, Prelutsky did not have a pulse. They performed CPR

and then took him to the hospital. Prelutsky was admitted to Aspen Valley

Hospital at 9:33 p.m., where he was then intubated and diagnosed with bilateral

subdural hematomas associated with a midline shift and skull fracture.

       At 9:51 p.m., a blood-alcohol test was performed. The test showed

Prelutsky’s blood-alcohol level was 281 mg/dL. 2 The following day, Prelutsky

was transferred to St. Mary’s Hospital in Grand Junction, Colorado, where a

craniectomy was performed. In April 2014, Prelutsky was transferred to a long-

term rehabilitation facility. Nine months after his injury, Prelutsky’s condition had

improved but he was still unable to return to work due to continuing cognitive

deficits and word-finding problems.

       In June 2014, Prelutsky applied to GGL for long-term disability benefits. To

conduct its initial review of Prelutsky’s claim, GGL obtained his medical records

from the rehabilitation facility. A report by attending physician Dr. Brock

       1
          The record does not show how much time passed between when Prelutsky fell and
when his son found him.
        2
          A level of 281 mg/dL equals a blood-alcohol concentration (“BAC”) of .281%. For
comparison, a BAC of .08% is the legal driving limit in every state. See Capone v. Aetna Life
Ins. Co., 592 F.3d 1189, 1193 n.3 (11th Cir. 2010).
        The toxicology report contained a disclaimer that said: “These unconfirmed ‘screening’
results are to be used for medical purposes only. They are not intended for non-medical
purposes (e.g. employment and/or legal testing).” However, Prelutsky does not challenge the
accuracy or reliability of the hospital’s determination that his BAC was .281% on the night of the
fall, and therefore we do not question it.
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Bowman listed as one of the “admitting diagnoses”: “alcohol abuse (binge

drinking) with a blood alcohol of 0.250 at the time of his fall.” 3 Dr. Bowman also

noted that Prelutsky had a history of “binge drink[ing] approximately 2-3 times per

week” and that his “[l]ast alcohol intake would have been at the time of the

accident.” In addition, a physical therapy discharge note by attending physician

Dr. Payal M. Fadia said: “Alcohol abuse reported with a blood alcohol level of

0.25 at the time of his fall.” In July 2014, GGL denied Prelutsky’s claim, citing

the Intoxication Exclusion and the fact that Prelutsky’s “blood alcohol level was

0.25 when tested at the hospital” after the fall. Prelutsky appealed the denial,

arguing that GGL failed to properly investigate his claim.

       Before deciding Prelutsky’s appeal, GGL compiled a more comprehensive

record, including many documents submitted by Prelutsky. In addition to the

records from the rehabilitation facility, GGL obtained: Prelutsky’s medical records

from the two hospitals where he was treated; a report from an independent

physician, Dr. Richard E. Sall; an affidavit from Cynthia Cameron, the owner of

the home where Prelutsky was staying when he fell; and pictures of the stairs as

they looked on the day of the accident.

       The medical records from Aspen Valley Hospital contained the blood-

alcohol test showing Prelutsky’s blood alcohol was 281 mg/dL on the night of the

       3
        We’ve been offered no explanation for why some medical records listed Prelutsky’s
BAC as .25% when the toxicology report showed a BAC of .281%.
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fall. The Aspen Valley records also included a report from consulting surgeon Dr.

William Rodman, which listed as one of Prelutsky’s diagnoses: “Intoxication

(blood alcohol 253).” The records from St. Mary’s Hospital, prepared the day after

the fall, stated that “[t]he patient[’]s BAL was 250 on admission,” and listed

“alcohol intoxication” among the final diagnoses. The consultation notes from

another physician, Dr. David James, listed “[a]cute alcohol intoxication” as one of

Prelutsky’s diagnoses, and indicated that the hospital should commence its alcohol

withdrawal protocol. A document titled “History and Physical Notes” said:

“Patient . . . is 53 year old attorney skiing in Aspen on family vacation. Had drank

heavily this evening; fall 20 carpeted steps with immediate LOC [loss of

consciousness].”

      As part of its review of Prelutsky’s appeal, GGL forwarded his medical

records to an independent physician, Dr. Richard E. Sall, who is board-certified in

forensic medicine. GGL asked Dr. Sall to assess whether Prelutsky’s “blood

alcohol level contribute[d] to his fall or were any other contributing factors

identified.” Dr. Sall determined that:

      [I]n my medical opinion, the claimant’s BAC contributed to his
      fall. . . . The claimant had a blood alcohol level of .281%. Since at
      0.25% BAC, the individual would need assistance in walking and
      have impaired coordination, it would contribute to his fall down the
      stairs.

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Dr. Sall concluded: “Considering all the facts and circumstances in this case, it is

my medical opinion that the claimant was Intoxicated at the time of admission to

the hospital and the level of intoxication most probably contributed to the cause for

falling down the steps.”

      In support of his appeal, Prelutsky produced an affidavit from Cynthia

Cameron, the owner of the home where Prelutsky fell. Cameron saw Prelutsky for

two “brief period[s] of time” on the night of the accident, though it is unclear how

much time passed between when she saw him and when he fell. Cameron said

Prelutsky did not “appear to be overtly intoxicated” and “was not stumbling or

falling down” when she saw him. She also said “[i]t is [her] personal belief that

[Prelutsky] probably slipped on his ski pants” because, when she saw him, he was

still wearing his ski pants, which were “longer than normal, designed to fit over ski

boots.” Cameron was not with Prelutsky when he fell and had no first-hand

observations of the accident.

      In January 2015, GGL upheld its denial of Prelutsky’s claim for long-term

disability benefits. Like the initial denial, GGL said Prelutsky’s disability was not

covered by the Plan because his disability fell under the Intoxication Exclusion.

Prelutsky then filed this ERISA action challenging GGL’s denial of his claim.

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       The parties filed cross motions for summary judgment. 4 In its summary

judgment decision, the district court first considered whether Prelutsky was “under

the voluntary influence of an intoxicant, in this case alcohol, when he was injured.”

The district court reviewed the evidence of intoxication and found that Prelutsky

“was intoxicated at the time of his fall.” The court then considered whether

Prelutsky’s injury was “caused by, resulted from, or was related to his being

intoxicated.” On de novo review (the first step of the ERISA analysis), the district

court found that the evidence did not support “a causal link” between Prelutsky’s

intoxication and his fall, and thus found GGL’s benefits-denial decision was

“wrong.” The court then proceeded to the next step of the ERISA analysis:

whether GGL’s decision to deny benefits was supported by “reasonable grounds.”

The court found that because GGL’s decision was based on “insufficient

investigation,” its decision to deny benefits was not supported by reasonable

grounds. As a result, the district court granted summary judgment in favor of

Prelutsky. GGL appealed.

                                              II.

       4
          GGL called its motion a “Motion for Judgment on the Administrative Record.” As we
have recognized, the motion that serves “as [a] vehicle[] for resolving conclusively” an ERISA
benefits-denial action is not a typical motion for summary judgment. See Blankenship v. Metro.
Life Ins. Co., 644 F.3d 1350, 1354 n.4 (11th Cir. 2011) (per curiam). Unlike the usual summary-
judgment standard, the district court in the ERISA context “does not take evidence, but, rather,
evaluates the reasonableness of an administrative determination in light of the record compiled
before the plan fiduciary.” Leahy v. Raytheon Co., 315 F.3d 11, 17–18 (1st Cir. 2002). Thus,
GGL properly named its final dispositive motion a “Motion for Judgment on the Administrative
Record.”
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      We review de novo a district court’s ruling on a plan administrator’s

decision to deny benefits, applying the same legal standards that governed the

district court’s decision. Blankenship, 644 F.3d at 1354. “Review of the plan

administrator’s denial of benefits is limited to consideration of the material

available to the administrator at the time it made its decision.” Id. Where a plan

administrator has denied a claim because of a policy exclusion, as GGL did here,

the burden is on the administrator to show that the “exclusion prevents coverage.”

Horton v. Reliance Std. Life Ins. Co., 141 F.3d 1038, 1040 (11th Cir. 1998) (per

curiam). We use a six-step test to review a plan administrator’s denial of benefits:

      (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.
      (5) If there is no conflict, then end the inquiry and affirm the decision.
      (6) If there is a conflict, the conflict should merely be a factor for the
      court to take into account when determining whether an
      administrator’s decision was arbitrary and capricious.

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Blankenship, 644 F.3d at 1355.

       Here, it is undisputed that GGL was vested with discretion in reviewing

claims under the Plan. Therefore, even assuming that GGL’s decision was “de

novo wrong,” as the district court found, the dispositive question is whether GGL’s

decision was arbitrary and capricious. See Jett v. Blue Cross & Blue Shield of

Ala., 890 F.2d 1137, 1139 (11th Cir. 1989). Thus, we will begin our analysis at

step three and determine whether GGL’s decision to deny Prelutsky’s claim was

arbitrary and capricious. “When conducting a review of an ERISA benefits denial

under an arbitrary and capricious standard . . ., the function of the court is to

determine whether there was a reasonable basis for the decision, based upon the

facts as known to the administrator at the time the decision was made.” 5 Id.

       The district court found that Prelutsky was intoxicated at the time of his fall,

and Prelutsky does not challenge that finding on appeal. However, in order for the

Intoxication Exclusion to apply, it is not enough merely to show that Prelutsky was

intoxicated at the time of his injury. Rather, Prelutsky’s injury must have been

“caused by, resulting from, or related to” his intoxication. Because GGL had a

       5
         We “equate the arbitrary and capricious standard with the abuse of discretion standard.”
Doyle v. Liberty Life Assur. Co. of Bos., 542 F.3d 1352, 1356 n.1 (11th Cir. 2008). Under this
standard, deference is “due both for the administrator’s plan interpretations and for [its] factual
determinations.” Blankenship, 644 F.3d at 1355 n.6.
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reasonable basis to conclude that Prelutsky’s injury was, at a minimum, “related

to” his intoxication, its denial of benefits was not an abuse of discretion.6

           GGL reviewed the complete medical-record history of Prelutsky’s brain

injury. The records contained undisputed toxicological evidence that, at the time

Prelutsky fell, his BAC was .281%—which the physicians who treated Prelutsky

diagnosed as “[a]cute alcohol intoxication.” The records describing his fall also

specifically mentioned that Prelutsky “[h]ad drank heavily this evening.” While

the treating physicians never expressly determined that Prelutsky’s intoxication

was the cause of his fall, the fact that they said he “[h]ad drank heavily this

evening” directly before noting that he “f[e]ll 20 carpeted steps” indicates that the

doctors believed Prelutsky’s intoxication was an important aspect of the

circumstances of his fall and provided important context for understanding the

nature of his fall.

       GGL then submitted Prelutsky’s medical records for review by Dr. Sall, an

independent forensic physician. Dr. Sall confirmed that Prelutsky’s intoxication

likely played a causal role in his fall. He explained that a person with Prelutsky’s

level of intoxication “needs assistance in walking” and “experiences total mental

confusion,” “slurred speech, incoordination, unsteady gait, . . . and stupor.”

       6
        “Related” is defined as “[c]onnected in some way; having relationship to or with
something else.” Black’s Law Dictionary 1479 (10th ed. 2014).

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Moreover, Dr. Sall’s ultimate conclusion was that Prelutsky’s “intoxication most

probably contributed to the cause for falling down the steps.” GGL was entitled to

rely on these expert findings to determine that Prelutsky’s injury was “related to”

his intoxication. See Turner v. Delta Family-Care Disability & Survivorship Plan,

291 F.3d 1270, 1274 (11th Cir. 2002) (per curiam) (holding that plan administrator

is “entitled to rely on the opinion of the independent medical examiner”). The

causal link between Prelutsky’s intoxication and his injury is especially strong

because his medical records show that, aside from the extreme intoxication, he was

a perfectly healthy middle-aged man, who was “[i]ndependent in all ways” and had

no condition that would make him prone to fall.

      The fact that Prelutsky submitted an affidavit from Cameron, who believed

Prelutsky “probably slipped on his ski pants,” does not render GGL’s conclusion

unreasonable. Cameron did not witness the fall. Neither did she indicate how

much time passed between when she last saw Prelutsky and when he fell. In light

of these limitations, GGL was entitled to discount Cameron’s “personal belief”

about what caused Prelutsky’s fall. We have held that a plan administrator is

permitted to rely on medical evidence over a conflicting witness account, even

when that account comes from a reliable eyewitness to the accident. See Capone,
592 F.3d at 1194, 1200. Certainly, GGL was entitled to rely on expert medical

evidence over an affidavit from someone who had not witnessed the accident. See

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Brown v. Blue Cross & Blue Shield of Ala., Inc., 898 F.2d 1556, 1572 (11th Cir.

1990) (“[A] fiduciary is entitled to choose an apparently more reliable source of

information when sources conflict.”). But even assuming that Prelutsky did trip on

his ski pants, it is not unreasonable to infer that Prelutsky’s highly-intoxicated state

was still “related to” his injury, because the symptoms of extreme intoxication

could have prevented him from catching himself, or covering his head, or

mitigating the impact of his fall in some other way.

       The district court said our decision in Capone required a finding that GGL’s

investigation was not sufficient “to reasonably find a causal link between

[Prelutsky’s] alcohol consumption and his fall.” The district court read Capone to

hold that the “causal link” between alcohol intoxication and injury must be

“supplemented by a further investigation by the insurer” if all the insurer has is a

“blood test and a list of physical symptoms expected at a certain blood alcohol

level.” But this was not the holding of Capone.7

       The plaintiff in Capone was severely injured when he struck his head on the

bottom of the ocean while diving off a dock in the Bahamas. 592 F.3d at 1192–93.

A test revealed he had a BAC of .244%. Id. at 1192–93. Relying solely on this

BAC and a medical treatise’s generic description that a person with such a BAC

would be “grossly impaired,” id. at 1194, the insurance company decided there was

       7
        Even accepting the district court’s reading of Capone, it would not govern here. GGL’s
evidence was not limited to a “blood test and a list of physical symptoms.”
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a causal connection between the plaintiff’s intoxication and his “decision to dive.”

Id. at 1200 (emphasis added). The insurance company made this determination

even though it knew the plaintiff was accompanied by other people who (1) also

decided to dive but had not consumed any alcohol, and (2) saw “the series of

events leading up to the [plaintiff’s] dive.” Id. The insurance company made no

attempt to interview these witnesses before it denied the plaintiff’s claim for

benefits. Id. 1199–1200. In other words, the company failed to investigate

witnesses who may well have directly contradicted the company’s theory of the

causal connection between the plaintiff’s intoxication and his injury. Reviewing

those facts, we concluded the company’s investigation was unreasonable. Id. at

1200.

        The situation here is very different from Capone. Unlike in Capone, there

were no witnesses to Prelutsky’s fall or to the “series of events leading up to” it.

Id. Thus, there were no other sources of direct evidence GGL could have

investigated that were likely to disprove what the evidence already showed:

Prelutsky’s extremely high level of intoxication was causally connected in some

way to his fall and subsequent injury. As a result, GGL’s determination that

Prelutsky’s claim was barred by the Intoxication Exclusion was supported by

reasonable grounds. See Blankenship, 644 F.3d at 1355.

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      Because we find there were reasonable grounds for GGL’s decision, we

must consider whether any conflict of interest renders GGL’s decision arbitrary

and capricious. Id. Here, the only conflict is the “structural” conflict of interest

that is always present when a plan administrator “both makes eligibility decisions

and pays awarded benefits out of its own funds.” Id. “The presence of a structural

conflict of interest—an unremarkable fact in today’s marketplace—constitutes no

license, in itself, for a court” to overturn an otherwise reasonable benefits decision.

Id. at 1356. Prelutsky has not shown that GGL’s conflict was anything other than

standard industry practice. Neither has he shown that GGL’s decision was in any

way “tainted by self-interest.” See id. at 1355 (“Where a conflict exists . . . the

burden remains on the plaintiff to show the decision was arbitrary; it is not the

defendant’s burden to prove its decision was not tainted by self-interest.”

(quotation omitted)). Indeed, it was only after an independent forensic physician

reviewed Prelutsky’s medical records and issued his report finding a causal link

between Prelutsky’s intoxication and his injury that GGL upheld its initial denial.

Therefore, we cannot say that GGL’s conflict of interest made its decision arbitrary

and capricious.

      REVERSED.

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