You know that the standard of review applied by courts will significantly impact how courts view an ERISA Plan administrator’s interpretation of an undefined plan term.

But what impact should an insurer’s policy manual have in assessing the “intent” of a plan term?  NOT MUCH.

This new case highlights both points.

Caldwell v. Unum Life Insurance Company of America, 2019 WL 4463495, ___Fed Appx. ___ (10th Cir. September 18, 2019)(Accidental death claim resulting from speeding vehicle excluded under “crime exclusion”: “[J]udicial reliance on a claims manual in this context is problematic when there is no evidence the manual was offered to, or even available to, an insured or otherwise used in advertising or closing a sale.”)

FACTS. Caldwell, an employee of Sinclair, died while driving on an unpaved road, and at nearly 40 miles per hour over the posted speed limit. Caldwell’s beneficiaries sought ERISA governed accidental death and life insurance benefits. Unum, the administrator, granted the life insurance benefit but denied the accidental death benefit because of an exclusion for “accidental losses caused by, contributed by, or resulting from[]…an attempt to commit or commission of a crime.” Speeding is a misdemeanor under Wyoming law. The plan conferred discretionary authority to the plan administrator.

The Caldwells argued that accidental death benefits were wrongfully denied because: (1) the term “crime” was not defined in the crime exclusion, (2) the term “crime” is capable of two different and contradictory interpretations; and, (3) Unum’s internal policy manual exempts traffic violations, including speeding from the definition of “crime.” 

ISSUE: Whether the Plan’s “Crime” exclusion includes speeding?

TENTH CIRCUIT HELD:

1. Under the abuse of discretion standard of review, “‘A decision denying benefits based on an interpretation of an ERISA provision survives arbitrary and capricious review so long as the interpretation is reasonable.’” Op. at 2.
2. Unum’s interpretation, that speeding was a ‘crime’, was reasonable.”  Op. at 2.
3. “[W]e agree with the district court that the policy manual does not purport to be definitive and has substantial play in the joints….At the end of its discussion of the crime exclusion, the manual states in bold type: ‘Reminder: Each claim is unique and must be evaluated on its own merits.  The actual policy governing the claim must be referenced.’” Op. at 2.
4. “[J]udicial reliance on a claims manual in this context is problematic when there is no evidence the manual was offered to, or even available to, an insured or otherwise used in advertising or closing a sale.”  Op. at 3.

NOTE: The dissent argued: The Plan’s “Crime” exclusion “is ambiguous… because the word “crime” is susceptible to two reasonable—albeit contradictory—interpretations: one covers speeding and one that excepts speeding.” Op. at 12. The dissent also relied on Unum’s policy manual to establish whether speeding was intended to be interpreted as a crime even though the dissent agreed “the [policy] manual is not the plan and cannot override the Plan terms……”  Op. at 14.