United States District Court, D. Maine
ORDER ON MOTION FOR JUDGMENT ON THE RECORD
A. WOODCOCK, JR. UNITED STATES DISTRICT JUDGE.
beneficiary of an accidental death and dismemberment
insurance policy challenges the insurer's decision to
deny benefits under the policy. Because the beneficiary's
claim is barred for failing to exhaust internal remedies and
because the insurer's denial for failure to provide
requested documents was reasonable, the Court grants judgment
in favor of the insurer.
FACTS AND PROCEDURAL HISTORY
Anderson (Decedent) was an employee of Bangor Publishing
Company or a related entity (BPC) and participated in an
employee benefit plan (the Plan). Administrative Record (AR)
1, 53. John Anderson's mother is Nancy Anderson, and his
father is Gale Anderson. Compl. ¶¶ 1-2 (ECF No. 1);
AR 6-7. Gale Anderson is the sole beneficiary under the Plan.
AR 28, 50.
Life Assurance Company of Boston (Liberty Life, named in the
caption as Liberty Mutual Insurance) issued a group life
insurance policy (the Policy) funding life insurance benefits
available through the Plan. AR 54-88. Liberty Life also
administers claims for life insurance benefits the Plan makes
available. AR 64, 71, 82-85. The Plan provides basic life and
accidental death and dismemberment (AD&D) benefits to
covered employees of BPC. AR 55-57.
the Plan, AD&D “benefits are payable when a Covered
Employee suffers a loss solely as the result of accidental
Injury that occurs while covered.” AR 74. However,
AD&D benefits are not payable “for any loss that is
contributed to or caused by . . . controlled substances . . .
that are voluntarily taken, ingested or injected, unless as
prescribed or administered by a Physician.” AR 79.
Benefits are also not payable for any loss caused or
contributed by “the presence of alcohol in the Covered
Person's blood which raises a presumption that the
Covered Person was under the influence of alcohol and
contributed to the cause of the accident.” Id.
the “Notice and Proof of Claim” provision of the
Plan, “Satisfactory Proof of loss must be given to
Liberty Life no later than 30 days after the date of
loss.” AR 85. “Failure to furnish such proof
within [30 days] shall not invalidate or reduce any claim if
it was not reasonably possible” to provide proof in
that time, but “[s]uch Proof must by furnished as soon
as reasonable possible, and in no event, except in the
absence of legal capacity of the claimant, later than one
year from the time Proof is otherwise required.”
Id. Liberty Life also “reserves the right to
determine if the Covered Person's Proof of loss is
satisfactory, ” id., and possesses “the
authority, in its sole discretion, to construe the terms of
[the Plan Document] and to determine benefit
eligibility.” AR 84.
The “Appeal Process” provision of the Plan
Liberty will notify in writing any Covered Person or
beneficiary whose claim is denied in whole or part. That
written notice will explain the reasons for denial. If the
claimant does not agree with the reasons given, he may
request an appeal of the claim. To do so, the claimant should
write to Liberty within 60 days after the notice of denial
the “Legal Proceedings” provision of the Plan,
“Legal actions are contingent upon first having
followed the Claims and Appeals procedure outlined in this
policy.” AR 84.
January 30, 2016, John Anderson died while operating a
snowmobile when it collided with a tree. AR 29, 48. At the
time of his death, the decedent had $45, 000 in basic life
coverage and $45, 000 in AD&D coverage under the Plan. AR
25, 50. On February 22, 2016, the decedent's employer
sent an “employee proof of death” form, a death
certificate, and a beneficiary designation form to Liberty
Life. AR 49-52.
The Documents Requests
February 25, 2016, Liberty Life sent the beneficiary, Gale
Anderson, a letter stating that it “will proceed with
our review of the [AD&D] claim submitted by [BPC].”
AR 42. Liberty Life also requested certain documents from him
to complete its investigation, including a police report,
witness statements, a toxicology report, an autopsy report,
and a signed authorization. Id. The letter also
recited the Plan's AD&D exclusions. AR 42-43.
April 1, 2016, Liberty Life sent a second letter requesting
the same list of documents set forth in its February 25, 2016
letter. AR 39. On May 4, 2016, Liberty Life sent a third
letter, reducing its document requests to the police report,
toxicology report, and a signed authorization from Mr.
Anderson in order to complete its “investigation of the
AD&D Benefits.” AR 36. Liberty Life sent two more
letters to Mr. Anderson requesting the same reduced set of
documents on June 9, 2016, and July 15, 2016. AR 30, 33.
27, 2016, Liberty Life paid the beneficiary, Mr. Anderson,
$45, 000 through his attorney for basic life insurance
benefits. AR 22, 25. In the letter enclosing the payment for
the basic life insurance claim, Liberty Life again requested
the expanded list of documents it first requested on February
25, 2016 in order to complete its investigation of the
AD&D claim. AR 22.
August 25, 2016, Liberty Life spoke with the assistant to Mr.
Anderson's attorney, who said she saw something come
through the other day and that she would send something to
Liberty Life. AR 6. On August 29, 2016, Liberty Life left a
telephone message with Mr. Anderson's attorney.
Id. On August 31, 2016, Mr. Anderson's attorney
advised Liberty Life that he had additional information that
he would send to Liberty Life by the end of the week. AR 5.
Mr. Anderson's attorney said that he thought there was
going to be a disagreement on the exclusion for intoxication,
and he indicated that he did not agree with the manner in
which the measurement was taken. AR 5-6.
September 30, 2016 and October 31, 2016, Liberty Life left
further telephone messages for Mr. Anderson's attorney.
AR 5. Liberty Life sent another letter requesting the
documents to Mr. Anderson's attorney on November 2, 2016.
December 5, 2016 Liberty Life sent another letter to Mr.
Anderson's attorney requesting the documents. AR 15. In
bold text, Liberty Life advised the attorney:
Please note, if these documents have not been
received within the next 30 days or by January 05, 2017, the
AD&D portion of this claim will be closed due to failure
January 11, 2017, Liberty Life sent Mr. Anderson's
attorney a letter recounting the series of communications and
informing him that no AD&D benefits are payable under the
Policy because “the requested documents for the
AD&D claim were not provided to Liberty within the Notice
and Proof of Loss time frame required under the
policy.” AR 10-12. The denial letter also excerpted the
“Notice and Proof of Claim” provision, AR 11, and
indicated that he “may request a review of this denial
by writing to the Liberty representative signing this
letter” and “[i]f Liberty does not receive your
written request within 60 days of your receipt of this
notice, our claim decision will be final, this file will
remain closed, and no further review of this claim will be
conducted.” AR 12.
is no evidence in the record that Mr. Anderson appealed
Liberty Life's adverse determination or that Mr. Anderson
(or his counsel) ever sent the requested documents to Liberty