Baptiste v. Securian Fin. Grp., Inc.

557 F.Supp.3d 1271

Rony Y. JEAN BAPTISTE, Plaintiff,

v.SECURIAN FINANCIAL GROUP, INC., et al., Defendants.

CASE NO. 20-60888-CIV-ALTMAN/Hunt

United States District Court, S.D. Florida.

Signed August 31, 2021

Rony Y. Jean Baptiste, Pembroke Pines, FL, Pro Se.

Kristina Beth Pett, Washington, DC, Lelia Maria Menendez Schleier, Wendy Lynn Furman, McDowell Hetherington LLP, Boca Raton, FL, for Defendants.

ORDER

ROY K. ALTMAN, UNITED STATES DISTRICT JUDGE

The Plaintiff, Rony Y. Jean Baptiste, is the beneficiary of his brother's life and accidental death and dismemberment insurance plans. After Jean Baptiste's brother died of a drug overdose, the insurer—Securian Life Insurance Company—paid Jean Baptiste the life insurance benefits. But it denied coverage for the accidental death benefits. In doing so, it notified Jean Baptiste that his brother's death was not a covered loss and that the overdose was otherwise excluded from coverage under certain plan provisions. As we explain below, this denial of accidental death benefits was neither arbitrary nor capricious—which means that, under the Employee Retirement Income Security Act of 1974 ("ERISA"), we cannot disturb Securian Life's decision. We therefore GRANT Securian Life's Motion for Summary Judgment (the "Motion") [ECF No. 30].

BACKGROUND ¹

I. THE POLICIES

Securian Life issued a group life insurance policy and a group accidental death and dismemberment ("AD&D") policy to Johns Hopkins University. See Joint SOMF ¶ 1. We refer to these as the "Policies," collectively, or as "Policy 70327" and "Policy 70328," respectively.² The former offers both life insurance and voluntary AD&D coverage, while the latter offers only AD&D coverage. Id. Ramses P. Mocombe, the Plaintiff's brother, was employed as a nurse anesthetist at Johns Hopkins and had enrolled in both Policies. Id. ¶ 2.

This case concerns only the AD&D benefits. Under the Policies, AD&D coverage is "limited," such that an insured is entitled to benefits "only when [his] loss, death or dismemberment, results, directly and independently from all other causes, from an accidental bodily injury which was unintended, unexpected and unforeseen." Id. ¶ 3. Furthermore, "[t]he bodily injury must be evidenced by a visible contusion or wound, except in the case of accidental drowning. The bodily injury must be the sole cause of [the insured's] death or dismemberment." Id.

Policy 70327 includes the following exclusion, which provides (in relevant part) that Securian Life isn't required to pay AD&D benefits when an insured's death:

is caused directly or indirectly by, results in whole or in part from or during, or there is contribution from [...] (3) [the insured's] participation in, or attempt to commit, a crime, assault, felony, or any illegal activity, regardless of any legal proceedings thereto; [...] (5) the use of alcohol; or (6) the use of prescription drugs, non-prescription drugs, illegal drugs, medications, poisons, gases, fumes, or other substances taken, absorbed, inhaled, ingested or injected.

Id. ¶ 4. Similarly, Policy 70328 doesn't require Securian Life to pay out benefits when an insured's death:

is caused directly or indirectly by, results in whole or in part from or during, or there is contribution from [...] (3) the insured's commission of, or attempt to commit a felony, or to which a contributing cause was [the insured's] being engaged in an illegal occupation; [...] [or] (5) a loss to which a contributing cause was the insured's being intoxicated or under the influence of any narcotic.

Id. ¶ 5. Both Policies confer discretionary authority on Securian Life by providing that "Securian Life has the exclusive right and authority, in its sole discretion to interpret the group policy and decide all matters arising thereunder. Securian Life's exercise of that authority shall be conclusive and binding on all persons unless it can be shown that the determination was arbitrary and capricious." Id. ¶ 6.

II. MR. MOCOMBE'S DEATH

On April 14, 2018 (while the Policies were in effect), Baltimore police officers found Mr. Mocombe dead in his apartment. Id. ¶ 7. According to the Incident Report, the officers found him "sitting on the bed slumped over on his right side with his face into the mattress." Id. He had an IV inserted in his hand, and vials of medications³ were scattered throughout his apartment. Id.

Maryland's Medical Examiner performed an autopsy. Id. ¶ 9. The autopsy report noted that there had been an "intravenous line taped to the back of the left hand" of the decedent and that "[t]here was no evidence of significant recent injury." Id. ¶ 10. The examiner opined that the decedent had self-administered substances intravenously and that he had ultimately died of "Diphenhydramine, Ketamine and Ethanol Intoxication with Fentanyl Use." Id. ¶¶ 11–12. Still, the "manner of death [was] best certified as COULD NOT BE DETERMINED." Id. The Medical Examiner later amended the report, maintaining her opinion that the decedent "died of Diphenhydramine, Ketamine and Ethanol Intoxication with Fentanyl Use," but adding that, "[p]er report, the Decedent had insomnia which he had been self-treating for years. No history of depression, suicidal ideations or prior suicide attempts was reported. The manner of death is ACCIDENT." Id. ¶ 13. She also prepared a Toxicology Report, which revealed traces of "diphenhydramine, ketamine, lidocaine, metroprolol, metroclopramide, and fentanyl in the Decedent's urine." Id. ¶ 14. Finally, the Toxicology Report included the results of a subclavian blood test, which showed 1.8 mg/L of diphenhydramine and 2.1 mg/L of ketamine in the decedent's system and a blood-alcohol level of .17%. Id.

The State of Maryland issued a Certificate of Death on May 9, 2018, listing the "direct[ ] cause of death" as diphenhydramine, ketamine, and ethanol intoxication with fentanyl use and indicating that the "injury occurred" because of drug use. Id. ¶ 15. A July 13, 2018 amendment to the Certificate of Death declared that the manner of death was an "accident." But that amendment reiterated that "drug use" had caused the death. Id. ¶ 16. Specifically, it concluded that diphenhydramine, ketamine, ethanol, and fentanyl had "directly caused" the death. Id.

III. THE PLAINTIFF'S CLAIM FOR BENEFITS

The Plaintiff submitted a claim for benefits on behalf of himself and Viotti A. Lefevre, the decedent's other brother. Id. ¶ 17. He contended that the decedent "passed away due to an accidental overdose of powerful sedatives, in his quest to combat debilitating insomnia." Id. ¶ 18. He appended to his claim copies of the Certificate of Death, the Incident Report, the Toxicology Report, and the Medical Examiner's Report. Id. Securian Life informed the Plaintiff that the brothers were entitled to life insurance benefits under Policy Number 70327, id. ¶ 19, but it denied their claim for AD&D benefits under both Policy 70327 and Policy 70328, id. ¶ 20. Securian Life explained that, "based on the information available to [it], the manner of death could not be determined, and no proof of accidental death as defined in this policy has been provided." Def.’s SOMF ¶ 21. Even if the death had been "accidental," Securian Life continued, "there [were] specific exclusions for this type of event"—namely, for losses "caused, resulting from, or contributed to by alcohol, prescription, nonprescription, and illegal drugs, medications, intoxication, and/or narcotics." Id.

The Plaintiff appealed the decision to Securian Life and advanced two arguments: (1) that Securian Life didn't have the benefit of the final Certificate of Death, the Toxicology Report, or the Medical Examiner's Report when it first reviewed the claim, and (2) that Securian Life misinterpreted or incorrectly applied the term "narcotic" as it appears in the policy exclusions. See Joint SOMF ¶¶ 21–22.⁴ The Plaintiff didn't, however, dispute Securian Life's position that the decedent had died from a drug overdose. Id. To the contrary, he conceded that the decedent "accidentally succumbed to a therapeutic use of medications"—though he added (without evidence) that the decedent was "legally qualified to prescribe and administer" the drugs and that he'd been self-prescribing those drugs "for several years to help combat Insomnia." Aug. 13, 2018 Letter [ECF No. 29-13] at 3; see also id. (noting that the "[d]eath was caused by an accidental overdoes [sic ] of a sleeping cocktail that [the decedent] had been prescribing to himself for years").

In reviewing the appeal, Securian Life reached out to Johns Hopkins, which represented that Mr. Mocombe wasn't permitted to write prescriptions and that he hadn't filled any prescriptions on his own behalf at any Johns Hopkins facility between April 14, 2017 and April 14, 2018. See Joint SOMF ¶ 23. Securian Life also ran a "ScriptCheck," which indicated that, between September 21, 2007 and April 3, 2018, Mr. Mocombe hadn't been prescribed any of the medications that were found in his home—other than one drug, Azithromycin—or any of the drugs found in his system. Id. ¶ 24. Securian Life then upheld its denial of AD&D benefits, informing the Plaintiff of this decision by letter dated December 12, 2018. Id. ¶ 25.

In that letter, Securian Life explained that Mr. Mocombe's death "was not the result of an accidental bodily injury" (as defined by the Policies) because (1) there wasn't any evidence of a visible contusion or wound and (2) injury or death was a foreseeable result of the high concentration of drugs and alcohol in the decedent's system. See Def.’s SOMF ¶ 26; see also id. (determining that "[t]he combination of ketamine, elevated levels of diphenhydramine, and an elevated ethanol level, more than likely led to significant central nervous depression, pulmonary dysfunction, hemodynamic instability, and death"). Securian Life further noted that, according to medical literature, the decedent's blood-alcohol level of .17% was just below the fatal range and that...