Riggs v. Metro. Life Ins. Co.

940 F.Supp.2d 172

Argia RIGGS Plaintiff,

v.METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

Civil Action No. 11–3455.

United States District Court, D. New Jersey.

April 18, 2013.

Alan C. Milstein, Esq., Sherman, Silverstein, Kohl, Rose & Podolsky, PC, Moorestown, NJ, for Plaintiff.

Randi F. Knepper, Esq., McElroy, Deutsch, Mulvaney & Carpenter, LLC, Newark, NJ, for Defendant.

OPINION

RODRIGUEZ, Senior District Judge.

This case concerns the tragic death of Mr. Terry Riggs. Plaintiff Argia Riggs, Mr. Riggs' wife, brought this suit pursuant to the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., challenging Defendant Metropolitan Life Insurance Company's (“MetLife”) denial of her application for optional life insurance benefits following the death of her husband based on the insurance policy's “suicide clause.” Before the Court are the parties' Cross–Motions for Summary Judgment [Dkts. 11, 15]. Ms. Riggs argues that the Court should grant summary judgment in her favor and reverse MetLife's decision because the claim administrator abused her discretion when applying the “suicide clause,” as Mr. Riggs' death was not a “suicide” under the meaning of the insurance policy. MetLife argues that the Court should grant summary judgment in its favor and uphold the claim administrator's decision because the claim administrator did not abuse her discretion in denying the claim.

The Court considered the parties' initial submissions and, on June 20, 2012, dismissed without prejudice the parties' Cross–Motions and gave the parties leave for simultaneous briefing on the definition of “suicide.” The Court has considered the arguments presented by the parties' supplemental submissions as well as those advanced during oral argument on December 12, 2012. For the reasons stated below, the Court must deny Ms. Riggs' Motion for Summary Judgment [Dkt. 11] and grant MetLife's Cross–Motion for Summary Judgment [Dkt. 15].

I. Jurisdiction

This Court has subject matter jurisdiction over this ERISA action pursuant to 28 U.S.C. § 1331. Venue is proper in this Court under 28 U.S.C. § 1391(b).

II. Factual and Procedural History

The facts presented herein are based on the undisputed administrative record ¹ attached as Exhibit A to Ms. Riggs' Motion for Summary Judgment, which includes: the NuStar Life Insurance Plan (ML 0001–0058); several Life Insurance Claim Forms and related documents, including the denial letters and copies of Mr. Riggs' Certificate of Death (ML 0059–0093); Dr. Ronald Maris' curriculum vitae (ML 0096–0134) and report (ML 0135–0155); Notes from Mr. Riggs' treating physician (ML 0156–0160); MetLife's Senior Referral Form used in Ms. Riggs' appeal of her benefits denial (ML 0161–0163); a letter from MetLife's Senior Claim Examiner, Group Life Claims Options, addressed to Ms. Riggs' attorney responding to her attorney's request for review of the denial of the claim (ML 0164–0165), and a form notifying an Account Manager that Ms. Riggs' claim was denied (ML 0166).

The events prior to Mr. Riggs' death are as follows. Dr. Maris' report indicates that for few years prior to 1991, Mr. Riggs took Zoloft, an antidepressant. (ML 0137) On November 17, 2009, Dr. John Wilkes, M.D., gave Mr. Riggs Abilify, an antipsychotic. (ML 0137) Because Abilify made Mr. Riggs feel “too lethargic,” on March 9, 2010, Mr. Riggs was prescribed Zyprexa, an antipsychotic. (ML 0160; ML 0137) After taking Zyprexa for three days, he told Ms. Riggs that he heard “uncontrollable thoughts and voices” and “it made him feel like killing himself.” (ML 0137) On Monday, March 15, 2010, Mr. Riggs called his physician, who prescribed Cymbalta, an SNRI antidepressant, and was told to visit the ER if he continued to feel suicidal. (ML 0137) That evening, Mr. Riggs telephoned a family friend and told her that he had negative thoughts, could not concentrate, and “heard voices telling him to kill himself.” (ML 0138).

At approximately 5:30 a.m. during the morning of March 17, 2010, when Ms. Riggs was preparing to take a shower, she heard a “bang.” (ML 0136) She returned to the master bedroom and found Mr. Riggs bleeding on the floor. (ML 0136; ML 0138) He shot himself in the head with a gun that he had kept under his bed for the previous 19 or more years. (ML 0137) Ms. Riggs called 911 and the emergency responders transported Mr. Riggs to Cooper Hospital in Camden, NJ, where he died approximately five hours later. (ML 0136–37) There was no toxicology report and his body was cremated. (ML 0137).

At the time of his death, Mr. Riggs worked as a maintenance mechanic for NuStar Gp, LLC (“NuStar”) and participated in the NuStar life insurance plan (“the Plan”). (ML 0059–0072; ML 0138) The Plan is funded by a policy of group life insurance issued by MetLife to NuStar. (ML 001–0058) Following Mr. Riggs' death, NuStar submitted an Employer's Statement to MetLife, indicating the following: Mr. Riggs died on March 17, 2010; Mr. Riggs last worked on March 16, 2010; Mr. Riggs was eligible for basic life insurance in the amount of $5,000 effective April 1, 2008, and Mr. Riggs' base annual salary was $65, 166.40. (ML 0059–0060; ML 0068–0069) NuStar also submitted a Benefit Enrollment Confirmation form, which stated that Mr. Riggs was enrolled for four times his base benefit salary, or $261,000, in optional life insurance benefits. (ML 0073) Additionally, MetLife received a Beneficiary Designation form, indicating that Mr. Riggs' primary beneficiary was Ms. Riggs, who was eligible to receive 100% of the benefits. (ML 0061).

On May 15, 2010, Ms. Riggs applied to MetLife for life insurance benefits under the Plan. (ML 0064–0066) In a letter dated July 14, 2010, MetLife denied her claim for benefits. (ML 0091) MetLife explained that page 49 of the Plan states:

Suicide

If You commit suicide within 2 years from the date Life Insurance for You takes effect We will not pay such insurance and Our liability will be limited as follows:

• any premium paid by You will be returned to the Beneficiary; and

• any premium paid by the Policyholder will be returned to the Policyholder

(ML 0091) MetLife explained that Mr. Riggs enrolled for Optional Life Insurance on April 1, 2008 and that the Certificate of Death issued by the State of New Jersey states that he died on March 17, 2010 as a result of “gunshot wound to head,” that Mr. Riggs “shot self,” and that the manner of death was “suicide.” (ML 0092) Accordingly, MetLife stated that it denied the claim, as Mr. Riggs “died within 2 years of the effective date as a result of suicide.” (ML 0092).

By way of correspondence dated February 17, 2011, Ms. Riggs appealed MetLife's claim determination. (ML 0095–0160) To support her appeal, she submitted the following documents: medical records from Mr. Riggs' psychiatrist; the thirty-eight page curriculum vitae of Dr. Ronald Maris, a board-certified forensic suicidologist; and a report issued by Dr. Maris that reviews Mr. Riggs' case. (ML 0095–0160).

Dr. Maris' report indicated that “to be classified and certified as a ‘suicide’ requires both the intent and motivation to suicide,” and that “it is well-known that antipsychotics (like Zyprexa and Abilify) and antidepressants (like Cymbalta and Zoloft) have side-effects that are associated with increased suicidality.” (ML 0138–0140) Dr. Maris opined that Mr. Riggs lacked both the intent and motivation to suicide.³ (ML 0138–0139) Specifically, he opined that Mr. Riggs lacked the intent to suicide, as he “had a psychotic episode produced or made worse by his Zyprexa ingestion and simply followed his ‘command hallucinations ’ to kill himself.” (ML 0139) (emphasis in original) Accordingly, Dr. Maris concluded that Mr. Riggs “was incapable of forming suicide intent” and that he acted “compulsively and impulsively to comply with his drug-induced hallucinations.” (ML 0139).

Dr. Maris also concluded that Mr. Riggs lacked the motivation to suicide, which concerns “not if someone intended to suicide, but rather why they wanted to die,” for example to escape from chronic mental or physical pain. (ML 0139) (emphasis in original) He noted that such motivation requires “the ability to reason and think clearly about the consequences of one's suicide.” (ML 0139) In psychotic or drug-induced suicides, the action “is not intended to resolve anything, but rather is an automatic response or irresistible impulse generated by a neurobiological, pharmacological condition of altered consciousness, often involving (as in Terry Riggs' case) psychotic delusions of hallucinations.” (ML 0139).

Dr. Maris also opined that Mr. Riggs was “at a low risk to suicide” prior to taking Zyprexa and Cymbalta. (ML 0146) Specifically, he identified fifteen common risk factors, or “predictors,” of suicide:

(1) Depressive illness, mental disorder, affective disorder; (2) Alcoholism, drug or substance abuse; (3) Suicide ideation, talk, preparation; (4) Prior suicide attempts; (5) Lethal methods to attempt suicide (esp. firearms); (6) Isolation, living alone, loss of social support, rejection; (7) Hopelessness, cognitive rigidity; (8) Being an older white male; (9) Modeling, suicide in the family, genetics; (10) Work problems, unemployment, occupation; (11) Marital, sexual, dating problems, family pathology; (12) Stress, negative life events; (13) Anger, aggression, impulsivity, irritability, 5–HT Flux; (14) Physical Illness; (15) Repetition and co mobidity of factors 1–14, “suicidal careers.”

(ML 0146) Dr. Maris opined that Mr. Riggs “only had 5–6 of the 15 known suicide risk factors,” which translates to “a 3–4 on a 10 point suicide risk scale or ‘low to moderate’ suicide risk.” (ML 0147) An individual is more likely to suicide based on the number of risk factors associated with that individual.⁴ Dr. Maris noted that “[a]bsent an acute drug reaction, it is not likely that an individual with only 33 to 40% of the known suicide risk factors would suicide.” (ML 0147) Here,...