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Ellis v. Usable Life

United States District Court, E.D. North Carolina, Southern Division

September 27, 2017

USABLE LIFE, Defendant.



         This cause comes before the Court on defendant's motion for summary judgment and plaintiffs request for entry of summary judgment in her favor. The appropriate response and reply have been filed, and the matter is ripe for ruling. For the reasons that follow, defendant's motion is granted.


         This case arises under the Employment Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001, et seq. Robert Frank Ellis, the decedent, was employed by May Exterminating Company prior to his death on June 2, 2015. May Exterminating sponsored an employee welfare benefit plan for eligible employees, which included group life and accidental death and dismemberment benefits. These benefits were funded by a group insurance policy issued by defendant to May Exterminating. The group life benefit through the plan was $25, 000 and the total amount of accidental death and dismemberment benefit available was $25, 000. Following Mr. Ellis' death defendant admitted to liability for the $25, 000 in death coverage but has denied liability for accidental death and dismemberment coverage, claiming that Mr. Ellis' death was not the result of an accident as that term is defined by the policy. Plaintiff is the mother of Mr. Ellis and a beneficiary under both the group life and accidental death and dismemberment benefits. The employee welfare benefit plan grants defendant discretionary authority to determine eligibility for participation or benefits and to interpret the terms of the policy. Plaintiff seeks review of defendant's denial of accidental death and dismemberment benefits pursuant to 29 U.S.C. § 1132(a)(1)(B).

         Mr. Ellis died after being stung by a bee. A corrected death certificate issued on November 23, 2015, indicates that Mr. Ellis' death was accidental and lists the following causes of death: anoxic encephalopathy, cardiac arrest, anaphylactic response, and bee sting(s). [DE 21-1 at 50].[1]Anoxic encephalopathy is listed as the final disease or condition resulting in death and bee sting(s) is listed as the underlying cause. In denying plaintiffs claim, defendant relied on the bodily infirmity exclusion under the policy. The policy excludes payment of accidental death and dismemberment benefits when a loss is caused directly or indirectly by:

         1. disease, bodily or mental infirmity, or infection ....

         Coverage is further limited to losses due to injury independent of all other causes, and the term accident or injury is defined as

Accidental bodily injury sustained by the covered person while insured under the policy which is the direct cause of the loss, independent of disease or bodily infirmity or any other cause.

[DE 21-2 at 27; 7].


         A motion for summary judgment may not be granted unless there are no genuine issues of material fact for trial and the movant is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(a). The moving party bears the initial burden of demonstrating the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). If that burden has been met, the non-moving party must then come forward and establish the specific material facts in dispute to survive summary judgment. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 588 (1986). In determining whether a genuine issue of material fact exists for trial, a trial court views the evidence and the inferences in the light most favorable to the nonmoving party. Scott v. Harris, 550 U.S. 372, 378 (2007). "A dispute is genuine if a reasonable jury could return a verdict for the nonmoving party.... and [a] fact is material if it might affect the outcome of the suit under the governing law." Libertarian Party of Virginia v. Judd, 718 F.3d 308, 313 (4th Cir. 2013) (internal quotations and citations omitted).

         The parties agree that the plan at issue provides defendant with the discretion to interpret the plan language and determine benefit eligibility, and thus that this Court reviews defendant's decision for abuse of discretion. See Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 111 (1989); Woods v. Prudential Ins. Co. of Am., 528 F.3d 320, 322 (4th Cir. 2008). When determining whether a plan administrator or fiduciary abused its discretion,

a court may consider, but is not limited to, such factors as: (1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary's interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decisionmaking process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary's motives and any conflict of interest it may have.

Booth v. Wal-Mart Stores, Inc. Associates Health and Welfare Plan, 201 F.3d 335, 342-43 (4th Cir. 2000). A court cannot disturb the policy administrator's decision if it was reasonable, even if the court would have reached a different conclusion. Id. at 341. "The administrator's decision is reasonable if it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence, which is evidence which a reasoning mind would accept as sufficient to support a particular conclusion." DuPerry v. Life Ins. Co. of N.A.,632 F.3d 860, 869 (4th Cir. 2011) (internal quotations and citations omitted). A court reviewing the plan administrator's decision for abuse of discretion is ...

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