Helton v. Acs Group

• Decision Date: 27 March 1997
• Docket Number: No. 3:95-CV-0614.,3:95-CV-0614.
• Citation: 964 F.Supp. 1175
• Court: U.S. District Court — Eastern District of Tennessee
• Parties: Ralph E. HELTON, Plaintiff, v. ACS GROUP, and J & S Cafeterias of Pigeon Forge, Inc., Defendants.

964 F.Supp. 1175

Ralph E. HELTON, Plaintiff, v. ACS GROUP, and J & S Cafeterias of Pigeon Forge, Inc., Defendants.

No. 3:95-CV-0614.

United States District Court, E.D. Tennessee.

March 27, 1997.

Memorandum and Order on Reconsideration March 27, 1997.

Gary E. Brewer, Brewer & Terry, PC, Morristown, TN, for Plaintiff.

Thomas C. McKee, Edward T. Brading, Herndon, Coleman, Brading & McKee, Johnson City, TN, for Defendants.

MEMORANDUM OPINION

JORDAN, District Judge.

This is an action arising under the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. §§ 1001, et seq. (ERISA). The defendants filed a motion for summary judgment [doc. 8; supporting brief, doc. 9; reply brief, doc. 13] to which the plaintiff responded in opposition [doc. 11]. The court has heard the oral argument of counsel for the parties, and is prepared to rule on the defendant's motion.

The plaintiff Mr. Helton was an employee of the defendant J & S Cafeterias of Pigeon Forge, Inc. (J & S). As such an employee, he participated in an employee welfare benefit plan consisting of a self-funded health care plan provided by J & S and administered by the defendant ACS Group (ACS).¹ As a result of a beating he received on May 9, 1994, the plaintiff submitted a claim for medical insurance benefits under this plan. The defendants admit that they denied the plaintiff's claim in reliance on two exclusions from coverage stated in the plan documents, one referring to "charges incurred for sickness or injury suffered in connection with or arising from the commission of a felony by a Covered Person," and one referring to "charges incurred for injuries sustained as the result of the misuse of a controlled substance where the controlled substance was not prescribed by a physician."

There is no dispute in this civil action concerning the applicability of ERISA or the court's jurisdiction of the subject matter under 28 U.S.C. § 1331. The court finds that this civil action does arise under ERISA, and that it therefore does have subject-matter jurisdiction of this action. At oral argument, counsel for the plaintiff conceded that review of the benefits claim denial in this case is under the more deferential arbitrary and capricious standard. Firestone Tire and Rubber Company v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Davis v. Kentucky Finance Cos. Retirement Plan, 887 F.2d 689, 694 (6th Cir.1989), cert. denied, 495 U.S. 905, 110 S.Ct. 1924, 109 L.Ed.2d 288 (1990).² Neither the plaintiff nor the defendants have suggested that this action is not properly before this court after full review of the plaintiff's claim in accordance with the administrative procedures required by the plan.

The administrative record, supplied as an exhibit to the declaration of ACS' Vice President of Claims Teresa Seymour [doc. 8, attachment], and compiled during the investigation of the plaintiff's claim, shows that on March 8, 1994, the Sevier County, Tennessee Circuit entered a restraining order in a civil action styled Anna Faye Helton v. Ralph Eugene Helton, restraining Mr. Helton, the plaintiff in this civil action, from calling, harassing, or coming about his wife or her family wherever the wife might be, or from interfering with his wife's physical custody of the parties' two minor children. On March 25, 1994, Mr. Helton pleaded guilty in the Sevier County Trial Justice Court to a misdemeanor charge of simple assault, the charge being that Mr. Helton, while driving a pickup truck, deliberately struck his wife's motor vehicle multiple times. The trial justice court imposed a sentence of 11 months and 29 days suspended to 10 days and probation for 11 months and 29 days, and restrained Mr. Helton from any further contact with his wife. On April 20, 1994, the Sevier County Circuit Court entered an order in the divorce action leaving a grandmother the temporary custodian of the parties' minor children, providing that Mrs. Helton "is allowed to return to the marital residences (sic) if she wishes to do so to the exclusion of the husband which privilege is not to be abused," stating certain visitation rights concerning the minor children, requiring both parties, upon their agreement, to submit to drug screen tests, and enjoining "all parties their heirs and assigns ... from interfering with the enforcement of this order."³

The plaintiff Mr. Helton did not obey the court orders concerning coming about his estranged wife; he suffered the beating out of which his claim for welfare benefit plan benefits arises in this case when he went purposefully to the lakeside residence at which his wife was staying. The police report of the May 9, 1994, incident [decl. of Teresa Seymour, ex. C] states that Mr. Helton requested a police officer to escort him to the lakeside residence because Mr. Helton anticipated fighting with two males there; that the dispatched officer did not meet the plaintiff before the fight at the residence, but met him afterwards when the plaintiff was driving his own vehicle, and that the plaintiff then told the officer that he had been struck in the head by the fist of one of the males at the residence; and that the witnesses at the residence told the officer that the plaintiff had started the fight by striking his wife with a stick.

Transcripts of telephone conversations apparently recorded by the plaintiff [id., ex. D] indicate violent, expletive-filled conversations between the plaintiff and his estranged wife and some of the other individuals at the lakeside residence just before the fight. The plaintiff initiated at least some of these telephone conversations. Any reasonable reading of these transcripts would indicate that the plaintiff knew or should have known that his arrival at the residence would lead to violence. Transcripts of police interviews of witnesses [id., ex. F] reveal varying recollections of the fight; there is some evidence that one man held the plaintiff while another struck him in the face and head, but there is also evidence that this did not occur, and that the plaintiff was struck only while his hands were free and he was fighting.

After the plaintiff commenced this civil action, the defendants deposed him [doc. 8, attachment, Deposition of Ralph Eugene Helton, January 30, 1996 (hereinafter "Helton depo.") ]. According to the ACS Vice President of Claims, Ms. Seymour, the defendant ACS again considered the plaintiff's claim, and concluded, "based on the deposition alone and separate and apart from [the] previous investigation," that on May 9, 1994, "Mr. Helton committed aggravated assaults against his wife and against Mr. Stephen Jackson and that the injuries Mr. Helton received were connected with or arose out of these aggravated assaults." [Decl. of Teresa Seymour at 5.] The defendant ACS therefore stood on its decision that the commission-of-a-felony exclusion in this welfare benefit plan applies in this case.⁴

At his deposition, the plaintiff testified that he knew that the Sevier County Circuit Court's restraining order required him to stay away from his wife. [Helton depo. at 35.] He understood that he was excluded from the lakeside residence by the other order entered by that court. [Id. at 38.] According to the plaintiff, when he first talked by telephone with his wife on the date he was injured, she invited him to come to the lakeside residence. He did not know during this conversation that there were others there, but he decided not to go in light of the restraining order. [Id. at 58.] It was only after the violent telephone conversation with one of the men at the lakeside residence that the plaintiff decided to go there.

As is stated above, the plaintiff called the police before he left his mother's home to go to the lakeside residence. [Id. at 59.] Once he arrived at the lakeside residence, the plaintiff again told someone to call 911, "[b]ecause [he] knew there was going to be trouble." [Id. at 75-76.] The plaintiff's reason for going to the lakeside residence was to remind his wife of the divorce judge's instruction that she not have "wild parties" there, but the plaintiff knew that his children were not there, he having left them with his mother. [Id. at 61-61.] When the plaintiff left his mother's home to go to his wife's residence, he put a stick several feet long in the bed of his pickup truck, for "protection." [Id. at 66.] "If I'd had a gun, I would have used it." [Id. at 65.] The plaintiff admits that at the outset of the confrontation on May 9, 1994, he slapped his wife several times in the face. [Id. at 96.]

Much of the parties' arguments in support of and in opposition to the defendants' Rule 56 motion deals with the definition of assault in Tennessee criminal law. The plaintiff devotes much argument to the facts that the benefits claim denials in this case were made by individuals with little knowledge of criminal law, that these individuals did not take into account the criminal-law standard of proof beyond a reasonable doubt, and that the plaintiff was neither charged with nor convicted of a felony as a result of his conduct on May 9, 1994. The plaintiff concedes that the acting plan administrator sought the advice of counsel concerning aggravated assault as it is defined in Tennessee law, but faults the defendants for not having consulted with the Tennessee Attorney General or with the district attorney general in the district in which this fight occurred. [See doc. 11 at 7.] By inviting this court to try the factual issues regarding whether Mr. Helton committed an aggravated assault on the day he was injured, the parties appear to ignore the fact that ERISA, not Tennessee insurance or criminal law, governs this civil action.⁵

A plan administrator's denial of an ERISA welfare benefit plan benefits claim is not arbitrary or capricious if it is rational in light of the plan's provisions. Miller, supra n. 4, at 984 (citation omitted). When discretion is granted to a plan...