462 F. App'x 804
10th Cir.2012Background
- Brimers seek ERISA benefits under a Life Insurance Co. of North America group policy for James Brimer’s death; district court denied.
- James Brimer died March 26, 2006; autopsy and toxicology indicated multiple drugs present; manner of death listed as accident.
- Policy excludes certain losses, notably exclusions 1 (intentionally self-inflicted), 6 (sickness/disease/medical treatment), and 7 (voluntary self-administration of non-prescribed drugs).
- Brimers’ claim was initially denied by LINA based on Exclusion 7; LINA later relied on additional grounds in administrative appeal, including Exclusion 6.
- District court Brimer I affirmed denial; Brimers won a post-judgment revision (Brimer II) that reversed on accident and found Exclusion 6 ambiguous, but the court still denied relief on other grounds.
- This appeal addresses whether LINA’s procedural handling under ERISA and the reading of Exclusions 6 and 7 support denial of benefits.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| ERISA procedure violated by relying on new grounds | Brimer argues ERISA required full and fair review with no new grounds on appeal. | LINA contends any grounds raised were within the policy framework and adequately linked to denial. | Procedural violation found, but no prejudice shown to Brimers. |
| Conflict/ambiguity between Exclusions 6 and 7 | Exclusions 6 and 7 conflict, rendering Exclusion 6 ambiguous and potentially supporting coverage. | Exclusions 6 and 7 are not ambiguously read in combination; Exclusion 6 precludes coverage. | Argument forfeited; court did not reach plain-error review. |
| Applicable standard of review | ERISA de novo review should apply to interpretation of policy exclusions. | Court applies de novo review consistent with Metro. Life v. Glenn. | De novo review applied for evaluating Exclusion 6/overall denial. |
| Exclusion 6 precludes coverage as a matter of law | Reading Exclusion 6 with 7 could yield coverage for prescribed-drug overdoses. | Exclusion 6 supports denial even for overdose cases; policy language controls. | Exclusion 6 precludes coverage; district court’s interpretation upheld. |
Key Cases Cited
- Robinson v. Aetna Life Ins. Co., 443 F.3d 389 (5th Cir. 2006) (prejudice required for ERISA procedural remand remedies)
- Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863 (9th Cir. 2008) (new grounds on appeal violate full and fair review)
- DiGregorio v. Hartford Comprehensive Emp. Benefit Serv. Co., 423 F.3d 6 (1st Cir. 2005) (prejudice required for ERISA remand when procedure violated)
- LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789 (10th Cir. 2010) (plan term ambiguity and contra proferentem principles)
- Rasenack ex rel. Tribolet v. AIG Life Ins. Co., 585 F.3d 1311 (10th Cir. 2009) (ambiguity and contra proferentem in ERISA plans)
- Miller v. Monumental Life Ins. Co., 502 F.3d 1245 (10th Cir. 2007) (interpretation of policy exclusions and ambiguity in context)
- Sage v. Automation, Inc. Pension Plan & Trust, 845 F.2d 885 (10th Cir. 1988) (remand futility when no additional evidence proffered)
- Recupero v. New England Tel. & Tel. Co., 118 F.3d 820 (1st Cir. 1997) (no remedy for ERISA violation where no prejudice shown)
- Richison v. Ernest Grp., Inc., 634 F.3d 1123 (10th Cir. 2011) (forfeiture and plain error standards in appeals)
- Graham v. Hartford Life & Accident Ins. Co., 589 F.3d 1345 (10th Cir. 2009) (de novo standard and standard of review)
- LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789 (10th Cir. 2010) (plain language and ambiguity in plan terms)