United States District Court, M.D. Tennessee, Nashville Division
CHRISTINE A. CARLSON PLAINTIFF
RELIANCE STANDARD LIFE INSURANCE COMPANY DEFENDANT
REPORT AND RECOMMENDATION
KING, MAGISTRATE JUDGE UNITED STATES DISTRICT COURT.
pending are cross motions for judgment on the record filed,
respectively, by Defendant Reliance Standard Life Insurance
Company (“Defendant” or “Reliance”)
and Plaintiff Christine A. Carlson (“Plaintiff”
or “Claimant”). (Docket Entry, hereinafter
“DE” Nos. 42 and 44). Plaintiff has filed a
response in opposition to Defendant's motion (DE 49), to
which Defendant has filed a subsequent reply. (DE 50).
Defendant has also filed a response in opposition to
Plaintiff's motion. (DE 47). Both motions have been
referred to Magistrate Judge Lanny King for report and
recommendation. (June 22, 2017, Docket Annotation).
reasons that follow, the undersigned Magistrate Judge
respectfully recommends that Defendant's motion (DE 42)
be DENIED and that Plaintiff's motion (DE 44) be GRANTED
IN PART, to the extent that the claim is remanded to the Plan
Administrator to perform a review of the entire
Administrative Record including the Supplemental Information.
matter involves Plaintiff's claim, as the widow of Barak
J. Carlson (the “Decedent”), who was a
participant within the meaning of 29 U.S.C. §1002(7), of
a group life insurance plan (the “Plan”) that was
issued by the Defendant.
December 28, 2010, Decedent applied for a life insurance
policy listing the Plaintiff as the sole beneficiary.
(Administrative Record, hereinafter “AR” 79). The
Decedent had a double-indemnity policy to which Plaintiff was
the sole beneficiary through the Plan. The life insurance was
effective on December 28, 2010, in the principal amount of
$250, 000.00 (the “Life Provision”) and an
accidental death policy (the “Accidental Death
Provision”) (together the “Policy”)
provided an additional $250, 000.000 in the event of an
accidental death. (AR 79-80). The Life Provision contains a
limitation precluding the payment of benefits if the insured
dies by suicide within two years of the effective date of
insurance coverage. (AR 484). The Accidental Death Provision
also excluded coverage when a loss is “caused by
suicide, or intentionally self-inflicted injuries.” (AR
October 20, 2012, the Decedent, armed with a shotgun, was
turkey hunting with his brother-in-law, Timothy Cox
(“Mr. Cox”). (AR 29). The two men were hunting
separately but in close proximity to each other; the Decedent
in a small tent-blind alone and Mr. Cox hunting nearby. (AR
112). Shortly after 5:00 p.m. Mr. Cox heard a gunshot and
attempted to text the Decedent to determine if he had shot a
turkey. (AR 112). A short time later, Mr. Cox having received
no response from Decedent, went to the blind and discovered
the body of the Decedent with a gunshot wound on the left
side of his neck. (AR 112).
initial investigative report of the Police Department (the
“Incident Report”) and the subsequent report of
the Office of the Medical Examiner (“OME”) (the
“Initial OME Report”), the Decedent's cause
of death was listed as suicide. (AR 114-15).
August 8, 2013, in a letter to Plaintiff, Defendant denied
Plaintiff's claims under the Policies based on the
findings that the OME listed suicide as the cause of
Decedent's death on the death certificate (the
“Claim Denial Letter”). (AR 105).
October 1, 2013, Plaintiff timely filed an appeal of the
denial of benefits (the “Appeal”). (AR 109). In
her Appeal Plaintiff supplied Defendant with a copy of the
police report and investigative report pertaining to the
Incident and a copy of the medical examiner's report
including a toxicology report. Id. Plaintiff also
notified Defendant that she was in the process of undertaking
an investigation of the Incident and believed that the
Incident was not the result of suicide, but an accident.
October 8, 2013, Defendant notified Plaintiff via letter that
it was in receipt of her Appeal (the “Initial Review
Notice”) and that Defendant would be conducting a
review (the “Appeal Review”) of the claim file.
(AR 46). The Initial Review Notice also informed Plaintiff
that Defendant would notify Plaintiff if Defendant required
additional information to make its appeal determination.
Id. The Initial Review Notice also stated that
Defendant would “toll the relevant time frames for
reaching an appeal determination from the time of [its]
request for additional information until such time as [it]
receive[d] the requested information [from Plaintiff]”
(the “Tolling Notice”). Id.
October 23, 2013, Defendant sent a letter notifying Plaintiff
that Defendant was granting Plaintiff until November 22, 2013
to supply Defendant with “any additional
information” that Plaintiff wished to be considered in
the Appeal Review of the file. (AR 48). In the October 23,
2013 letter, Defendant granted itself a tolling of the
initial 60-day review period by stating: “the statutory
[sic] time frames for reaching an appeal determination will
be tolled until such time as we receive the requested
information from you.” Id. The letter,
however, did not request any specific information from
November 21, 2013, Plaintiff sent a letter to Defendant
requesting additional time to supply Defendant with the
following information: witness statements and a crime scene
expert's report. (AR 141). On November 22, 2013,
Defendant sent another letter stating it was in receipt of
Plaintiff's November 21, 2013 letter and was granting
Plaintiff through December 13, 2013 to supply any information
Plaintiff wished to be considered by Defendant in its Appeal
Review. (AR 49). Defendant again repeated the same tolling
language used in its October 23, 2013 letter and stated that
the 21 day additional time for submission was required
because “statutory and internal guidelines set strict
deadlines for completion of an appeal review.” (AR 49).
Again, Defendant's November 22, 2013 letter did not
request any specific information from Plaintiff. Id.
December 13, 2013 counsel for Plaintiff wrote to Defendant
and attached a copy of Detective Johnny Lawrence's
investigation report. (AR 541-42). The December 13, 2013
letter also notified Defendant that Dr. Zimmerman, the
medical examiner from Davidson County who performed the
initial medical evaluation of the Decedent, was reopening the
case and reviewing his findings based on the information
contained in Jonny Lawrence's investigation report.
Id. In addition to the notification that Dr.
Zimmerman was in the process of performing a file review
after having reopened the case, Plaintiff listed
“additional facts” that Plaintiff wished to be
considered by Defendant in its Appeal Review, indicated that
Plaintiff was still investigating the claim, and that
Plaintiff expected her investigation to be complete by
mid-January 2014. Id.
January 14, 2014 Defendant wrote to counsel for Plaintiff
providing Plaintiff an “update regarding your
client's claim” and formally notifying Plaintiff
that “this letter serves as notice of our intention to
take beyond 60 days to make a final decision on the
appeal.” (AR 0050). Defendant's letter stated that
“[w]e are required to make a decision within 60 days of
the date of the appeal but are allowed an additional 60 days
if circumstances do not permit us to make a decision within
the initial 60 day time frame” (the “Extension
Notice”). Id. Defendant's Extension Notice
did not request any additional information from Plaintiff nor
did it indicate a time when it anticipated a decision would
be rendered, instead stating “we will be contacting you
in the near future with an update or to inform you if
additional information will be required.” Id.
The Extension Notice letter also did not repeat the Tolling
Notice language that was found in its prior notices nor did
it otherwise inform Plaintiff that it was properly able to
toll the Extension Period while waiting for Plaintiff to
submit any additional documentation.
January 16, 2014 Defendant notified Plaintiff that it would
be submitting the claim for review by an independent
examiner. (AR 0155). On January 25, 2014, Defendant wrote to
counsel for Plaintiff reminding Plaintiff of the
“strict deadlines for completion of an appeal review,
” and requested that Plaintiff provide: incident
photographs, autopsy photographs, and any information
regarding the testing of the gun. (AR 0159). The January 25,
2014 letter also notified Plaintiff that it was tolling
“the statutory time frames for reaching an appeal
determination” until receipt of the requested
January 27, 2014, Plaintiff provided some of the information
requested in the January 25, 2014 letter and provided the
autopsy photographs on February 24, 2014. (AR 651-74).
March 11, 2014, the OME of Davidson County completed his
review and amended his report (the “Amended OME
Report”) to change the manner of death from
“suicide” to a finding that “the manner of
death in this case could not be determined.” (DE 29,
March 21, 2014, Defendant notified Plaintiff that its review
was complete and the denial of benefits was being upheld (the
“Appeal Denial”). (AR 0775). It is uncontested
that Defendant did not consider the Amended OME Report prior
to issuing its Appeal Denial. Id.
March 31, 2014, the OME certified its Amended OME Report. (DE
29, ex. 1). Also on March 31, 2014, counsel for Plaintiff was
notified of the certification of the Amended OME Report and
obtained a certified copy. (Id. at 3).
timely filed suit against Defendant in the Circuit Court for
Davidson County, Tennessee, which was later removed to this
Court on or about February 3, 2015, claiming (among other
claims) that Defendant breached its contract by failing to
pay benefits under the Policy. (DE #1).
November 3, 2015, Plaintiff filed a Motion to Supplement the
Administrative Record (DE #29) requesting that Plaintiff be
allowed to supplement the administrative record to include
the Amended OME Report and to allow Plaintiff additional time
to provide relevant witness statements “necessary to
complete a proper investigation and review of this
matter.” (DE #29 at 3). Plaintiff's Motion to
Supplement was granted, and Plaintiff supplemented the
Administrative Record with the Amended OME Report and a Final
Investigation Report of Agente, LLC (the “Final
Investigation Report”), which included witness
statements (DE Nos. 38-1 and 38-2) (together the
November 1, 2016, a Magistrate Judge issued a Memorandum of
Opinion allowing Plaintiff to Supplement the Administrative
Record with the Supplemental Information, which was upheld by
the District Court. (DE 39).
core issue in this action is whether Defendant conducted a
full and fair review of Plaintiff's claim regarding the
death of Decedent without considering the Supplemental
Information submitted by Plaintiff. (DE 39 at 2). Pursuant to
the Court's prior order, if the Defendant violated ERISA
procedures when making its Appeal Determination without
considering the Supplemental Information, then the claim
should be remanded to the administrator to consider the
supplemental evidence. (Id.)
Standard of Review
participant or beneficiary of an ERISA plan may bring suit in
federal district court to recover benefits allegedly due
under the terms of the plan. Univ. Hosps. of Cleveland v.
Emerson Elec. Co., 202 F.3d 839, 845 (6th Cir. 2000)
(referencing 29 U.S.C. § 1132(a)(1)(B)). A plan
fiduciary's denial of a claim for ERISA benefits is
reviewed 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); see also Yeager v.
Reliance Standard Life Ins. Co., 88 F.3d 376, 380 (6th
Cir. 1996). If the plan gives discretion to the administrator
or fiduciary, then the benefit denial is reviewed under an
"arbitrary and capricious" standard. Id.
Here, Plaintiff conceded the administrator has discretion in
this case and agreed with the Defendant that the arbitrary
and capricious standard of review applies to the instant
matter. (DE 45 at 5).
issue in this case, however, is not whether the language in
Defendant's plan gives it discretionary authority, but
whether Defendant loses any discretion that it may have had
because of its alleged procedural failure to
exercise its discretion in accordance with the ERISA statute
and regulations. See Id. (arguing that Defendant
procedurally failed to conduct a full and fair evaluation of
the claim); (DE #39 at 2-3) (ordering the undersigned
Magistrate Judge to make a determination as to whether
Defendant procedurally failed to provide Plaintiff with a
full and fair review as required under ERISA). As such, this
Court must apply the standard of review used by the courts
when determining if the procedure employed by the
fiduciary in denying the claim meets ERISA's procedural
was enacted by Congress to establish procedural safeguards to
ensure that fiduciaries such as Defendant administer benefit
plans “solely in the interest of the participants and
beneficiaries.” 29 U.S.C. §§ 1104(a)(1) and
1001(b). Under ERISA, the Secretary of Labor is given
authority by Congress to enact regulations and set deadlines
for the administration of employee benefit claims. 29 U.S.C.
§§ 1133 and 1135. Those rules and regulations are
codified in 29 C.F.R. § 2560.503-1, titled “Claims
procedure” (the “Procedural Regulations”)
stating that every employee benefit plan shall “afford
a reasonable opportunity to any participant whose claim for
benefits has been denied for a full and fair review by the
appropriate named fiduciary of the decision denying the
claim.” 29 U.S.C. §§ 1133 and 1135.
benefits determination on appeal must be made within a
certain time. 29 C.F.R. § 2560.503-1(i)(4). Failure to
follow these procedures is governed by 29 ...