Nicole Cultrona v. Nationwide Life Ins. Co.
748 F.3d 698
| 6th Cir. | 2014Background
- Nicole Cultrona, designated beneficiary under Nationwide’s Death Benefit Plan, claimed accidental-death benefits after the June 2011 death of her husband, Shawn, whose autopsy listed cause/manner as positional asphyxia and acute ethanol intoxication (blood alcohol .22%).
- StarLine (claims administrator) and Nationwide reviewed investigative and medical examiner materials and denied the claim based on Exclusion 12 (intoxication-related exclusion), initially citing an outdated version of that exclusion (which referenced driving) but correcting the error and relying on an amended version that excluded deaths where the covered person is deemed intoxicated under the law of the locale.
- Nicole exhausted internal appeals; the Benefits Administrative Committee (BAC) affirmed the denial, concluding Shawn’s acute ethanol intoxication triggered Exclusion 12.
- Nicole sued under ERISA seeking benefits and statutory penalties for the BAC’s delay in producing plan documents; the district court granted judgment to defendants on the benefits claim but awarded Nicole $55/day (total $8,910) under 29 U.S.C. § 1132(c)(1) for late production of the policy.
- On appeal, Nicole argued the denial was arbitrary and capricious (conflict of interest, shifting rationales, failure to obtain independent medical review, and improper application of “law of the locale”); BAC argued the penalty was improper and that Nicole’s document request lacked clear notice.
- The Sixth Circuit affirmed: it applied arbitrary-and-capricious review to the benefit denial (finding the coroner’s report and related materials provided substantial evidence), adopted a clear-notice standard for future § 1024(b)(4) requests, and upheld the district court’s discretionary penalty and amount.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether denial of accidental-death benefits was arbitrary and capricious | Cultrona: BAC conflicted and denied benefits without independent medical review; coroner’s findings insufficient and LOC (locale) meant municipal law | BAC: denial based on coroner’s report and state law presumption; no medical dispute; decision supported by substantial evidence | Affirmed — denial not arbitrary or capricious; BAC reasonably relied on coroner’s findings and state law |
| Whether BAC’s conflict of interest required remand | Cultrona: BAC composed of Nationwide employees, so conflict, aggravated by file-only review | BAC: conflict is a factor but not dispositive; medical examiner served as independent medical source | Affirmed — conflict insufficient to overcome substantial evidence of denial |
| Meaning of “law of the locale” in Exclusion 12 | Cultrona: phrase refers to local (city/county) law, not state law; ORC §313.19 inapplicable | BAC: phrase reasonably read to mean state law; coroner’s determinations entitled to legal effect under ORC §313.19 | Affirmed — “law of the locale” reasonably construed as state law; coroner’s report supported exclusion |
| Whether BAC abused discretion by failing to promptly furnish plan policy and whether penalty amount was proper | Cultrona: requested all documents; BAC delayed production of policy — seeks maximum penalty | BAC: request was too broad/ambiguous; court should apply a clear-notice standard and deny or reduce penalty | Affirmed — adopted clear-notice standard going forward but concluded BAC should have known policy was requested; district court did not abuse discretion in imposing $55/day |
Key Cases Cited
- Helfman v. GE Grp. Life Assurance Co., 573 F.3d 383 (6th Cir.) (standard for reviewing ERISA benefit denials when administrator has discretion)
- Judge v. Metro. Life Ins. Co., 710 F.3d 651 (6th Cir.) (conflict of interest is a factor, not dispositive)
- McClain v. Eaton Corp. Disability Plan, 740 F.3d 1059 (6th Cir.) (consistency of rationale matters in administrative denials)
- Vargo v. Travelers Ins. Co., 516 N.E.2d 226 (Ohio) (coroner’s report and death certificate create a rebuttable presumption regarding cause of death)
- Kollman v. Hewitt Assocs., LLC, 487 F.3d 139 (3d Cir.) (clear-notice standard for document requests under § 1024(b)(4))
- Minadeo v. ICI Paints, 398 F.3d 751 (6th Cir.) (purpose of ERISA disclosure provisions and penalties)