Justia Insurance Law Opinion Summaries

Appellant, the named beneficiary of an accident benefits plan that her husband obtained through his employer, brought suit under ERISA, 29 U.S.C. 1001 et seq., alleging that the plan administrator, Metropolitan Life Insurance (Metlife), abused its discretion in determining that her husband was intoxicated at the time of the accident and denying coverage. At issue was whether the district court properly granted summary judgment to Metlife because Metlife's interpretation of the relevant policies was arbitrary and capricious and not supported by substantial evidence. The court held that Metlife did not abuse its discretion as plan administrator when it denied benefits based on the general exclusion for intoxication that appeared in the certificate of insurance. The court also held that the toxicology report, which concluded that the husband's blood alcohol level was above the state limit, constituted evidence that a reasonable mind might accept as adequate to support a conclusion and therefore, satisfied the substantial evidence standard. The court also held that because it agreed with the district court's conclusion that the denial of benefits was justified in light of the intoxication conclusion, it need not address Metlife's assertion that the husband's death was not accidental because it was reasonably foreseeable or, alternatively, the result of intentional self-inflicted injury. Accordingly, summary judgment was affirmed.

Appellants filed suit against nine pilots and their spouses asserting claims for equitable relief under 29 U.S.C. 1132(a)(3) of ERISA where appellants alleged that the pilots and their spouses obtained "sham" divorces for the purpose of obtaining lump sum pension distributions from the Continental Pilots Retirement Plan. At issue was whether ERISA, 29 U.S.C. 1056(d)(1), allowed a retirement plan administrator to seek restitution of benefits that were paid to a plan participant's ex-spouse pursuant to a domestic relations order such as a divorce decree, if the administrator subsequently determined that the domestic relations order was based on a "sham" divorce. The court agreed with the district court's holding that subsection 1056(d)(3)(D)(i) did not authorize an administrator to consider or investigate the subjective intentions or good faith underlying a divorce. Therefore, the court affirmed the district court's dismissal of appellants' claims.

Plaintiff, the father of decedent, commenced an action seeking to recover from defendants, decedent's grandparents, for decedent's wrongful death and for her conscious pain and suffering where she accidentally drowned in defendants' pool. At issue was an exclusion in defendants' homeowner's insurance policy excluding coverage for bodily injury to an insured where an insured would receive "any benefit" under the policy. The court held that judgment should have been granted in plaintiff's favor where the exclusion did not operate to bar coverage for the noninsured plaintiff's wrongful death claim for the death of the insured decedent. Accordingly, the court reversed the Appellate Division's judgment and remanded for further proceedings.

The biological mother of three children lived with the children and their adoptive mother and named the adoptive mother as beneficiary on one of her life insurance policies through her employer. She did not name beneficiaries on other policies and, after she died, the insurers rejected claims on behalf of the children. The district court dismissed claims under the Employee Income Security Act (ERISA), 29 U.S.C. 1001, which lists children as default beneficiaries. The Third Circuit vacated and remanded. ERISA grants standing to participants and beneficiaries; whether the term "children," as used in the insurance contracts, includes biological children who have been adopted by a non-participant is ambiguous. There was evidence of the insured's intent to benefit the children, sufficient to create a colorable claim adequate to support standing.