Brown v. PFL Life Insurance

United States Court of Appeals
Fifth Circuit
F I L E D
IN THE UNITED STATES COURT OF APPEALS
October 1, 2004
FOR THE FIFTH CIRCUIT
Charles R. Fulbruge III
____________________ Clerk

No. 04-60208

Summary Calendar
____________________

DAWN BROWN

Plaintiff - Appellant

v.

PFL LIFE INSURANCE CO

Defendant - Appellee

_________________________________________________________________

Appeal from the United States District Court
for the Northern District of Mississippi, Aberdeen
No. 1:02-CV-212
_________________________________________________________________

Before KING, Chief Judge, and HIGGINBOTHAM and PRADO, Circuit
Judges.

PER CURIAM:*

Plaintiff-Appellant, Dawn Brown (“Brown”), is the designated

beneficiary of an accidental death insurance policy under which

her father, Terry Gilmer (“Gilmer”), was the insured. The plan

*
Pursuant to 5TH CIR. R. 47.5, the court has determined
that this opinion should not be published and is not precedent
except under the limited circumstances set forth in 5TH CIR. R.
47.5.4.
 No. 04-60208
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administrator concluded that Gilmer did not die as a result of an

accident as defined in the policy and thus, denied Brown’s claim

for benefits under the policy. Brown appeals the district

court’s holding that the plan administrator did not abuse its

discretion in denying her the benefits. For the following

reasons, we AFFIRM the judgment of the district court.

I. Background

Gilmer was an employee of Nolen Sistrunk, Inc. (“Sistrunk”),

a Mississippi trucking company. At the beginning of his

employment, Gilmer accepted an accidental death insurance policy

offered by Sistrunk. PFL Life Insurance Company (“PFL”)

administered and financed the policy. Gilmer designated his

daughter, Brown, as the policy’s beneficiary. She would receive

$1,000 per month, for life, guaranteed for twenty years, upon

proof that the insured’s death resulted directly from an

accident.

On June 22, 1999, Gilmer died following a traffic accident.

The accident occurred while he was driving his employer’s truck

east on Interstate 20 in Louisiana. According to witnesses,

Gilmer’s truck swerved and crashed into the back of another

truck. The police report stated that at the time of the accident

the road conditions were good, the weather was clear, and there

were no visual obscurities. In addition, the truck Gilmer was

driving, as well as the other truck, had no known defects.
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Brown timely submitted a claim to PFL under the accidental

death insurance policy. PFL denied Brown’s claim after an

investigation in which it concluded that Gilmer’s death did not

fall within the terms of the policy. PFL found that Gilmer

suffered a cardiac event while he was driving and that caused the

collision. PFL therefore concluded that Gilmer’s heart attack

contributed to his death and thus, that his death was not the

result of an accident as defined in the policy.

Brown subsequently brought an action against PFL asserting a

claim for bad faith denial of benefits in the Circuit Court of

Attala County, Mississippi. PFL removed the case to the United

States District Court for the Northern District of Mississippi.

After a non-jury trial, the district court entered judgment for

PFL holding that PFL’s decision to deny the accidental death

benefits was not an abuse of discretion because, inter alia, its

decision was neither arbitrary nor capricious.

II. Discussion

A. Standard of Review

The Employee Retirement Income Security Act provides the

district courts with the authority to review a plan

administrator’s denial of plan benefits. 29 U.S.C.

§ 1132(a)(1)(B) (2004). The district court reviews a plan

administrator’s factual determinations for an abuse of discretion

when it has denied benefits under a plan. Vercher v. Alexander &
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Alexander, Inc., 379 F.3d 222, 226 (5th Cir. 2004) (citing

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989));

Pierre v. Connecticut Gen. Life Ins., 932 F.2d 1552 (5th Cir.

1991), cert. denied, 502 U.S. 973 (1991)). In applying the abuse

of discretion standard, the district court analyzes whether the

plan administrator acted arbitrarily or capriciously. Bellaire

Gen. Hosp. v. Blue Cross Blue Shield of Mich., 97 F.3d 822, 829

(5th Cir. 1996). A plan administrator’s decision is deemed

arbitrary if it is made “without a rational connection between

the known facts and the decision or between the found facts and

the evidence.” Lain v. Unum Life Ins. of Am., 279 F.3d 337, 342

(5th Cir. 2002) (quoting Bellaire Gen. Hosp., 97 F.3d at 828).

An administrator’s decision must be based on evidence, even if

disputable, that clearly supports the basis for denial, and there

must be some concrete evidence in the record to support the plan

administrator’s decision. Vega v. Nat’l Life Ins. Servs., Inc.,

188 F.3d 287, 299 (5th Cir. 1999). The district court, in

reviewing the plan administrator’s decision, can only consider

the evidence that was before the plan administrator. Id.

We in turn review de novo the district court’s legal

conclusion that the plan administrator abused its discretion.

Hammack v. Baroid Corp., 142 F.3d 266, 270 (5th Cir. 1998)

(citing Sunbeam-Oster Co. Group Benefits Plan v. Whitehurst, 102

F.3d 1368, 1373 (5th Cir. 1996)).
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B. Analysis

We first examine the terms of the accidental death insurance

policy. The relevant terms of the policy provide that the

benefits would be payable upon proof that the “insured’s death

resulted directly from accidental bodily injury and independently

of disease or bodily infirmity or any other cause.” The terms of

the policy further provide that the benefits would not “be

payable if death results, directly or indirectly . . . or is

contributed to, wholly or in part, by . . . disease or medical or

surgical treatment of disease . . . .”

We now turn to the relevant evidence before PFL, which

consisted of Gilmer’s death certificate, an autopsy report, the

statements of the doctor who performed the autopsy, Gilmer’s

medical records, the police report, and the investigating

officer’s statements. The death certificate provided that acute

and ongoing myocardial infarction, i.e, a heart attack, was a

significant cause of Gilmer’s death. The autopsy report provided

that Gilmer’s death “was due to multiple traumatic injuries” and

that “[t]here was no evidence of recent abuse of ethanol or other

common drugs.” The autopsy report also stated that Gilmer “had

ongoing myocardial infarction, with recent thrombosis of the left

coronary artery” that “may have caused the accident.” Upon

questioning, the doctor who performed the autopsy, Dr. Young,

stated that Gilmer was having a heart attack for some time. Dr.
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Young, however, maintained only that the heart attack “may have

caused” the accident.

Gilmer’s medical records revealed that he suffered from high

blood pressure, which was poorly controlled, complained of

shortness of breath and dizziness, and was a smoker. Moreover,

as previously discussed, the police report indicated that the

weather and road conditions were good when Gilmer’s truck swerved

and hit the other truck. Further, the accident investigator,

after referring to the autopsy report, attributed the accident to

the fact that Gilmer was suffering a cardiac event, or, less

likely, fell asleep at the wheel.

Brown’s argues on appeal that PFL could deny the benefits

only if the heart attack was the probable cause of Gilmer’s

death. This argument is unavailing. Under the abuse of the

discretion standard, PFL’s decision need only evince a “rational

connection between the known facts and the decision.” Lain, 279

F.3d at 342 (quoting Bellaire Gen. Hosp., 97 F.3d at 828).

Considering all the evidence before PFL, it could have rationally

concluded that Gilmer’s heart attack contributed to his death.

Specifically, the undisputed evidence shows that Gilmer’s health

was poor, that he was having a heart attack while he was driving,

that nothing about the road conditions or the weather could be

said to have contributed to the accident, and that in the opinion

of two experienced professionals--Dr. Young and the investigator-
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-the heart attack may have caused the accident. A rational

conclusion from this evidence is that Gilmer was suffering a

heart attack that impaired his ability to drive and caused him to

swerve into the other truck. As such, PFL’s conclusion was not

arbitrary or capricious, and PFL had a sound basis for denying

Brown’s claim for benefits under the terms of the policy.

III. Conclusion

For the foregoing reasons, we agree with the district court

that PFL did not abuse its discretion when it denied Brown the

benefits under the accidental death insurance policy. We

therefore AFFIRM the judgment of the district court.