District Court Rejects Sun Life’s Attempt to Argue New Grounds for Denying Accidental Death Benefits, Denies Motion to Remand

In Rushing v. Sun Life Assurance Company of Canada, Civil Action 22-cv-1454 (W.D. La. Nov. 1, 2022), Western District of Louisiana Magistrate Judge Mark L. Hornsby denied Sun Life’s motion to Stay and Remand this ERISA case for further administrative review.

Plaintiff Katie Rushing filed a claim for benefits under an employer-sponsored Accidental Death and Dismemberment (AD&D) Policy after her husband, Matthew, died in an auto accident. Matthew’s vehicle had inexplicably crossed a center line and caused a head-on collision that killed both Matthew and the driver of the other vehicle. Sun Life, the insurer and administrator of the benefits plan, collected the accident report, autopsy report, and toxicology report. The toxicology report showed positive findings for Dextro-Levo Methorphan, a non-prescription cough suppressant sometimes abused for recreational use, and Promethazine, an antihistamine, sedative, and anti-nausea medication. Side effects from the two medications can cause sedation, confusion, and even hallucinations.

Sun Life approved Mrs. Rushing’s life insurance claim but denied the accidental death benefits claim on grounds that Matthew’s death was not an accident as defined by the policy. Per the policy, an accident is a sudden and accidental event that results independently of other causes and is independent of any illness, disease, or other bodily malfunction. Sun Life also determined that the claim was resulting from committing criminal acts, falling under a policy exclusion.

After Ms. Rushing filed an administrative appeal for accidental death benefits, Sun Life undertook further review and was informed by State Police that Matthew would have been cited with a traffic code violation such as careless operation, but he would not have been charged with a criminal act. State police noted no illegal substances were found in the toxicology report. Sun Life still upheld its decision to deny the accidental death benefit on the basis that it was not an accident as defined by the policy. Sun Life reasoned that it was not unforeseen that driving across the center line of traffic would result in bodily harm and death.

After Ms. Rushing filed a civil lawsuit, Sun Life’s Counsel argued that allegedly high concentrations of the medications found in the toxicology report would affect Matthew’s driving such that the crash would not be an unforeseeable event independent of all other causes. Sun Life moved for remand of the case for a full and fair review of the claim that fully discusses the toxicology report. The court, however, explained that remand was not appropriate because Sun Life had already determined both at the claim and appeal stages that Matthew’s death did not meet the definition of accident under the policy and the plaintiff had a full opportunity to contest it. The court explained, “Remand may be appropriate to provide a remedy to a claimant who has been denied a full and fair opportunity to address an issue during the administrative process, but it is not appropriate for the plan or insurer to wait until a case is in federal court and then seek remand to build a new basis for denial that it reasonably could have developed during the administrative process.” Sun Life had the toxicology report from the beginning and already had its opportunity to build evidence regarding the effect of medications found in Matthew’s blood. The court thus denied Sun Life’s motion to stay and remand.

If Sun Life has denied your life insurance or accidental death claim, contact us for assistance.