Cole ex rel. Th. C. v. Am. Heritage Life Ins. Co.
Cole ex rel. Th. C. v. Am. Heritage Life Ins. Co.
Opinion of the Court
OPINION AND ORDER
Plaintiff November Cole brought this ERISA action on behalf of her minor children to recover life insurance benefits under a group insurance policy purchased by her late husband, Thomas H. Cole, Sr., through his employer. Mr. Cole tragically died by suicide on January 2, 2016 and the Plaintiffs filed a claim for benefits under the group policy. Their claim was denied pursuant to the group policy's suicide exclusion.
What appears to be a fairly straightforward case is complicated by the timeline of events. Mr. Cole originally began paying into a policy offered by a different insurance company on January 1, 2014. That policy did not contain a suicide exclusion and he paid into that policy until January 1, 2016. Sometime prior to that date, Mr. Cole's employer contracted with a new insurance company to provide this particular employee benefit effective January 1, 2016. The policy of the new company, Defendant American Heritage Life Insurance Company, contained a suicide exclusion limiting the benefit amount to the premiums paid if the insured committed suicide within 2 years of the certification date. The new policy went into effect on January 1, 2016, one day before Mr. Cole took his own life.
The issue to be decided is whether the second policy was merely an extension of the first policy or whether it stands alone. The Coles argue that the two policies should be read together and the alleged ambiguities that result should be interpreted in favor of coverage. American Heritage argues that its denial was reasonable and appropriate. It asks, why should American Heritage be held responsible under some other insurer's policy language? The parties filed cross motions for summary judgment on the issue of coverage. For the reasons discussed below, I find that American Heritage's denial of the Coles' claim pursuant to the policy's suicide exclusion was reasonable and, therefore, grant American Heritage's motion for summary judgment.
Background
Thomas H. Cole, Sr. was the husband of November Cole and the father to three children. [DE 29 at 2.] Mr. Cole was an employee at Forest River, Inc. in Elkhart, Indiana. [Id. ] Beginning on January 1, 2014, Mr. Cole enrolled in, and began paying premiums for, an optional $100,000 life insurance policy through Forest River's employee plan provided by the Lincoln National Life Insurance Company. [Id. ] At some point in 2015, Forest River terminated its group policy with Lincoln National and purchased a group policy from American Heritage that was set to go into effect on January 1, 2016. [DE 35-2 at ¶ 1.]
Forest River's full-time active employees were eligible to participate in its ERISA benefit plan, including the American Heritage Group Policy. [DE 35-2 at ¶ 2.] American Heritage's Group Term Life Insurance Certificate explains the "Certificate Date" as "[t]he effective date of coverage under this certificate and the *591date from which the certificate, years, anniversaries and premium due dates are determined. The certificate date is shown on the Certificate Specifications page." [DE 35-1 at ¶ 9; DE 35-1 at 53.] The Certificate Specifications page for the American Heritage Group Policy states "Certificate Date: January 1, 2016." [DE 35-1 at ¶ 9; DE 35-1 at 51.] The Certificate also contains a "Suicide Exclusion" that explains, "[i]f the insured commits suicide, while sane or insane, within 2 years after the certificate date, the death benefits is limited to the premiums paid." [DE 35-1 at ¶ 11; DE 35-1 at 56.] The American Heritage Group Policy contains the same exclusion. [DE 35-1 at ¶ 11; DE 35-1 at 17.]
Mr. Cole died by suicide on January 2, 2016, one day after the American Heritage Group Policy's Certificate Date. [DE 35-2 at ¶ 12.] Mrs. Cole notified American Heritage of the death via telephone call on March 28, 2016 and, after two written requests by American Heritage, submitted a death certificate and claim form on May 4, 2016. [Id. at ¶¶ 13-15.] The death certificate reported the cause of death as a self-inflicted gunshot to the chest and the manner of death as suicide. [DE 35-2 at ¶ 17; DE 29 at 6.] By a letter dated May 19, 2016, American Heritage issued a denial letter to Mrs. Cole based on the Suicide Exclusion under the Group Policy and Certificate. [DE 35-2 at ¶ 20; DE 29 at 7.] The letter also noted that there were no premiums paid for coverage under the Group Policy. [DE 35-2 at ¶ 20; DE 29 at 7.]
Mrs. Cole retained counsel who contacted American Heritage requesting copies of the Group Policy, Certificate, and American Heritage's coverage determinations and asking for a written articulation for any coverage denial. [DE 35-2 at ¶ 21; DE 29 at 7.] American Heritage sent counsel copies of the requested information and noted that if the Coles had any additional information that was not previously considered in support of their claim or would like to appeal the claim, they should send the information to the attention of the author of the letter. [DE 35-2 at ¶ 22; DE 29 at 7; DE 35-1 at 91.] The Coles sought reconsideration of the denial but American Heritage stuck by its initial decision of no coverage. [DE 29 at 7.]
The Coles filed this lawsuit in state court seeking a declaratory judgment against American Heritage and the matter was timely removed to this Court. The Coles eventually amended their Complaint dropping all of their state law claims and asserting only an ERISA benefit claim pursuant to
Discussion
Summary judgment is proper "if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). A genuine dispute about a material fact exists only "if the evidence is such that a reasonable jury could return a verdict for the non-moving party." Anderson v. Liberty Lobby, Inc. ,
With respect to an employee benefit plan governed by ERISA, a plaintiff may bring an action "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of *592the plan, or to clarify his rights to future benefits under the terms of the plan."
I consider the denial of benefits de novo unless the plan grants the plan administrator discretionary authority to construe policy terms. Cheney ,
Here, the only language that American Heritage points to in support of its argument that the plan grants discretionary authority is the following:
Proof of death must be by a certified copy of the death certificate or by other written evidence satisfactory to us. We may also require the certificate to be submitted with the proof of death.
We may provide an enhancement to the minimum death benefit amount. We have sole discretion to declare the amount and frequency of an enhancement to the minimum death benefit.
[DE 35-1 at 12 (emphasis added).] That language does not confer interpretive discretion regarding claim denial "in no uncertain terms." Rather, it clearly relates to the decision-and only the decision-to enhance the death benefit amount. So American Heritage is not entitled to the more deferential standard of review, and instead I will consider the denial of benefits de novo .
What do novo review means is that "[i]n an ERISA case, the district court 'must come to an independent decision on both the legal and factual issues that form the basis of the claim.' " Marantz v. Permanente Medical Group, Inc. Long Term Disability Plan ,
This case starts and ends with the Suicide Exclusion. The existence and *593terms of the Suicide Exclusion are undisputed. The question before me is what is the proper commencement date of the Suicide Exclusion. The Coles argue that the Suicide Exclusion has been satisfied by virtue of Mr. Cole's prior coverage under the Lincoln National Group Policy. Specifically, they argue that the Lincoln National Group Policy, under which Mr. Cole was covered for two years, was merely converted to the American Heritage Group Policy, which covered Mr. Cole for one additional day prior to his death, meaning that Mr. Cole met the two year requirement of the American Heritage Suicide Exclusion by one day, entitling the Coles to benefits. [DE 29 at 17-18.]
The Coles rely primarily on Commonwealth Life Ins. Co. v. Jackson ,
In conducting its analysis, the Commonwealth court analyzed a series of both federal and state cases on the issue of allowing the date of another insurance policy to serve as the commencement date of a later-issued policy's suicide exclusionary period. The cases reaching the same result as Commonwealth had common factors: (1) the insurance carriers were the same; (2) the second policy was a conversion of the first; (3) the carrier for the second policy did not require evidence of insurability and/or an application for coverage; (4) the second policy was dependent on the first policy for its existence and/or the second policy was derived from terms in the first policy; (5) both policies contained a suicide exclusion; and/or (6) the terms and conditions of the second policy were substantially similar to the first policy.
Indiana state and federal courts subsequently have addressed similar issues regarding the commencement of a suicide exclusionary period. In First Life Assurance Co. et al. v. Counting House Bank ,
In Pekin Life Ins. Co. v. Kopitzke ,
The Pekin court applied the same rationale as the First Life court, noting that: (1) the case did not involve a conversion policy, but an entirely new term policy; (2) Pekin did not waive evidence of insurability issuing the 2008 policy, requiring the insured to submit an entirely new application and complete a medical examination to obtain the policy; and (3) there was nothing in the 1999 policy that compelled or obligated Pekin to issue the 2008 policy, that is, the policies were not dependent on one another.
Consideration of the factors analyzed in Commonwealth and the cases that follow results in the conclusion that the American Heritage Group Policy was sufficiently distinct from the Lincoln National Group Policy such that the date of the commencement of the suicide exclusion under the *595American Heritage Group Policy is the effective date of that policy. Here, the Lincoln National Group Policy and the American Heritage Group Policy are separate policies making no reference to one another, issued by two different insurance companies, like the policies in First Life . The issuance of coverage under the American Heritage Group Policy had no bearing on whether the insured had prior coverage under the Lincoln National Group Policy and is not a conversion policy, like the policies in First Life and Pekin . Furthermore, the insured had to complete an "Enrollment and Evidence of Insurability Form" for the American Heritage Group Policy, which contained questions regarding the insurability of the insured, DE 35-1 at 28, like the insured in Pekin . Finally, the policies have different terms, most notably, the absence of a suicide exclusion in the Lincoln National Group Policy. See, e.g. , The Wellinger Family Tr. 1998 v. Hartford Life & Accident Ins. Co., No. 11-CV-2568-CMA-BNB,
Accordingly, because the effective date of the American Heritage Group Policy was January 1, 2016 and Mr. Cole took his life on January 2, 2016, the Coles' claim for benefits under the American Heritage Group Policy was properly denied pursuant to the Suicide Exclusion. As such, American Heritage's motion for summary judgment will be granted and the Coles' motion for partial summary judgment will be denied.
Conclusion
For the foregoing reasons, Defendant American Heritage Insurance Company's motion for summary judgment, DE 35, is GRANTED and Plaintiffs' motion for partial summary judgment, DE 28, is DENIED. The Clerk is DIRECTED to enter judgment in favor of American Heritage Insurance Company. The Clerk shall treat this civil action as TERMINATED .
SO ORDERED.
Reference
- Full Case Name
- November COLE ON BEHALF OF TH. C., Tr. C., and C.C. v. AMERICAN HERITAGE LIFE INSURANCE COMPANY
- Status
- Published