In River v. Edward D. Jones Co., No. 10-2586 (8th Cir. 2011), Beverly River was the named beneficiary of an accidental benefits plan (the “Plan”) that her husband, David Polk, obtained through his employer, Edward D. Jones & Co. After Polk died in a motorcycle accident, the plan administrator, Metropolitan Life Insurance (“Metlife”), determined that Polk was intoxicated at the time of the accident, and denied River’s entitlement to a death benefit from the Plan on that basis. River brought suit for this benefit under ERISA, alleging that Metlife had abused its discretion. The district court granted Metlife’s motion for summary judgment. River appealed.
On September 22, 2007, Polk and River met with friends at Mark Twain Lake in Ralls County, northwest of St. Louis, Missouri. They ate lunch together and Polk consumed five beers between 11:00 a.m. and 5:00 p.m. He left the campground on a motorcycle. Around 5:25 p.m., he lost control on a curve and was thrown from the motorcycle, striking a tree and sustaining fatal head injuries. The Ralls County coroner’s report stated that the cause of death was severe head trauma. In a certified toxicology report issued in October 2007, the Missouri State Highway Crime Laboratory Division stated that Polk’s blood alcohol content (BAC) was 0.128%.
The Plan grants Metlife, its claims administrator, the discretion to interpret the terms of the Plan and to make eligibility determinations. The Plan’s Certificate of Insurance had an intoxication exclusion for benefits. It stated that “We will not pay benefits under this section for any loss if the injured party is intoxicated at the time of the incident and is the operator of a vehicle or other device involved in the incident.” The Certificate also stated that “Intoxicated means that the injured person’s blood alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident occurred (a BAC of 0.128% exceeds this level in Missouri).”
The Eighth Circuit Court of Appeals (the “Court”) noted that when, as here, the plan grants a claims administrator the discretion to determine whether a claimant is eligible for benefits, the administrator’s decision on benefit entitlement is reviewed for abuse of discretion. In such case, a court will reverse the claims administrator’s determination only if it is arbitrary and capricious. Based on the intoxication exclusion in the Certificate of Insurance by itself (and considering that the Polk’s BAC exceeded 0.128%), the Court concluded that Metlife did not abuse its discretion as claims administrator when it denied the death benefit. Metlife reasonably concluded that Polk was intoxicated at the time of the incident resulting in his death, and denied benefits on the basis of the Plan’s clear language. As such, the Court upheld Metlife’s decision to deny the River the death benefit, and it affirmed the summary judgment granted by the district court.