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Lake v. Aetna Life Ins. Co.

United States District Court, D. New Jersey

October 21, 2014

MARIA LAKE, Executor for the Estate of Ronald Lake, and Surviving Spouse of Decedent Ronald Lake, Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY, JOHN DOE, and JOHN DOE INSURANCE COMPANY, Defendants

Editorial Note:

This Pagination of this case accurately reflects the pagination of the original published, though it may appears out of sequence.

Page 332

For Maria Lake, Plaintiff: Jennifer L. Gottschalk, Esq., THE LAW OFFICES OF RICHARD SPARACO, Cherry Hill, New Jersey.

For Aetna Life Insurance Company, Defendant: Eric J. Bronstein, Esq., ELLIOTT GREENLEAF & SIEDZIKOWSKI, P.C., Blue Bell, Pennsylvania.

OPINION

HONORABLE JOSEPH E. IRENAS, Senior United States District Judge.

Plaintiff Maria Lake brings this action to recover accidental death benefits under a policy underwritten by Defendant Aetna Life Insurance Company (" Defendant" or " Aetna" ).

Currently pending before the Court are Plaintiff's motion for judgment on the pleadings and Defendant's motion for summary judgment. For the reasons explained herein,

Page 333

Plaintiff's motion is DENIED and Defendant's motion is GRANTED.

I. FACTS

The Court recites those facts relevant to deciding the pending motions for judgment on the pleadings and summary judgment and resolves any disputed facts or inferences in regards to each motion in favor of the nonmoving parties.

On September 28, 2011, Ronald Lake (" Decedent" ) was killed as a result of a single-car crash when his vehicle veered off a road and struck a tree. (Plaintiff's Counter Statement of Material Facts (" P.C.S.M.F." ) ¶ 1; Medical Examiner's Report, Ex. A to Defendant's Motion for Summary Judgment (D.M.S.J.) at 158-60) The accident occurred around 1:00 a.m. and Decedent was pronounced dead approximately three hours later at 4:08 a.m. at Cooper University Hospital in Camden, New Jersey. (Med. Examiner's Rpt., Ex. A at 159) He was forty-six years old. (Id.)

A New Jersey Police Crash Investigation Report (" Police Report" ) described the relevant roadway as straight, level, and clearly marked with painted lines. (Police Report, Ex. A at 132-33) At the time of the incident, it was raining slightly, the roadway was wet, and it was dark in the area. (Id. at 133) There was no traffic on the road when Decedent crashed. (Id.)

The police investigation of the incident revealed the following sequence of events:

Vehicle #1 was traveling southbound on North Main Street when Vehicle #1 crossed over the northbound lane and ran off the left side of the roadway. Vehicle #1 continued in motion with the driver side tires off the roadway in a grassy graded ditch and then struck a tree with the front driver's side.

(Id.) Decedent sustained massive internal injuries as a result of the crash and died as a result of those injuries. A Toxicology Report issued by the Burlington County Medical Examiner's office found that Decedent's blood alcohol concentration (" BAC" ) was 0.133% w/v. (Toxicology Report, Ex. A at 162) The legal limit under New Jersey law is 0.08% w/v. See N.J. Stat. Ann. 39:4-50. Plaintiff states that the Toxicology Report was based on blood drawn at approximately 2:30 a.m. (P.C.S.M.F. ¶ 28) The Toxicology Report indicates that the blood was drawn postmortem. (Ex. A, at 162)

At the time of his death, Decedent was a participant in the IBEW Local 269 Welfare Fund benefit plan (the " Plan" ), which is funded by a group life insurance policy (the " Policy" ) issued by Defendant. Defendant is a " fiduciary" under the Policy with the " discretionary authority" to " determine whether and to what extent members and beneficiaries are entitled to benefits." (Aetna Group Life and Accident and Health Insurance Policy, Ex. A at 123) The Policy is governed by the Employment Retirement Income Security Act of 1974 (" ERISA" ), 29 U.S.C. § 1001 et seq. (Id. at 83)

The Policy provides a Life Insurance sum of $20,000, and Accidental Death and Dismemberment (" AD& D" ) benefits, which include a principal benefit amount of $20,000 and an Education Benefit Maximum for dependent children in the amount of 5% of the principal sum not to exceed $5,000 per year per child for up to four years. (Id. at 79) To secure payment of AD& D benefits, an insured must meet certain requirements. Specifically, the benefits are payable if " you suffer a bodily injury caused by an accident; and if, within 365 days after the accident and as a direct result of the injury, you lose . . . your life." (Id. at 60-61)

Page 334

The Policy puts forth certain restrictions on the payment of AD& D benefits as well. Benefits are not payable for a loss " caused or contributed to by . . . [a]n intentionally self-inflicted injury . . . . [or] [a] covered person's being intoxicated or being under the influence of narcotics unless administered or consumed on the advice of a physician." (Id. at 65)

On November 28, 2011, following Defendant's receipt of a completed Proof of Death claim form, Beneficiary designation, certified Death Certificate, and Death Notice from the internet, Defendant accepted Plaintiff's claim for life insurance benefits of $20,000 and sent her a check in that amount, but referred Plaintiff's claim for AD& D benefits to a claim analyst. (D.S.U.M.F. ¶ ¶ 9-12) Defendant denied Plaintiff's claim for AD& D benefits on April 20, 2012 after completing its review of the Police Report and Toxicology Report.[1] (Id. at ¶ 30)

On that same day, Defendant sent Plaintiff a letter stating that Defendant was denying AD& D benefits because the Plan's language precluded coverage where an accident was caused or contributed to by Decedent's intoxication. (Id. at ¶ 32) The letter explained that Defendants made this decision based on its review of the police and toxicology reports, among other documents. (Letter Denying AD& D Coverage, Ex. A at 170-73) Defendant also advised Plaintiff that she had the right to request a review of Defendant's decision within sixty days of the receipt of the letter, and to file a civil action under ERISA if the denial was upheld on appeal. (Id.; D.S.U.M.F. ¶ ¶ 34-35)

Plaintiff states that she recalls having mailed a letter to Defendant " in or around April 20, 2012" requesting that Defendant reconsider its decision to deny AD& D benefits. (P.C.S.F. ΒΆ 36) Defendant claims it did not receive any correspondence from Plaintiff until December 28, 2012, when Plaintiff's counsel contacted Defendant and requested a copy of the Plan. (D.S.U.M.F. ...


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