The Court of Appeals for the Eighth Circuit ruled that an insurer was not arbitrary and capricious as plan administrator when it denied accidental death and dismemberment benefits to a widow based on the general exclusion for intoxication that appeared in the certificate of insurance. The widow was the named beneficiary of an accidental benefits plan that her husband, the covered employee, obtained through his employer. After the covered employee died as a result of a motorcycle accident, the plan administrator determined he was intoxicated at the time of the accident and denied coverage. The widow brought suit under the Employee Retirement Income Security Act (ERISA), alleging the plan administrator abused its discretion. Evidence presented included a certified toxicology report in which it was stated that the covered employee’s blood alcohol content (BAC) was 0.128% at the time of the accident. The plan administrator moved for summary judgment, contending that it was justified in denying benefits based on the language of the policy. The federal trial court granted the motion, concluding that the summary plan description (SPD) was not deficient in apprising the average plan participant that benefits would be denied for injuries incurred as a result of operating a vehicle while intoxicated, and that even if it was deficient, the widow failed to establish that the covered employee had detrimentally relied on that information. The district court also concluded that it was not unreasonable for the plan administrator to deny benefits based either on the intoxication exclusion in the certificate of insurance or on similar exclusions in the SPD.
The widow appealed, contending that the trial court erred because the plan administrator’s interpretation of the relevant policies was arbitrary and capricious, and not supported by substantial evidence. The Eighth Circuit disagreed with the widow and upheld the grant summary judgment in favor of the plan administrator. In reaching its decision, the appellate court concluded that based on the intoxication exclusion alone the plan administrator did not abuse its discretion as plan administrator when it denied benefits. (River v. Edward D. Jones Co., 8th Cir. 2011)