Jessen v. Cigna Grp. Ins.

• Decision Date: 21 June 2011
• Docket Number: Case No. 09–12280.
• Citation: 812 F.Supp.2d 805
• Parties: Lisa JESSEN, Plaintiff, v. CIGNA GROUP INSURANCE and Life Insurance Company of North America, Defendants.
• Court: U.S. District Court — Eastern District of Michigan

812 F.Supp.2d 805

Lisa JESSEN, Plaintiff,

v.CIGNA GROUP INSURANCE and Life Insurance Company of North America, Defendants.

Case No. 09–12280.

United States District Court, E.D. Michigan, Southern Division.

June 21, 2011.

David Z. Adler, Jaffe, Raitt, Southfield, MI, for Plaintiff.

Brian T. Quinn, Honigman, Miller, Lansing, MI, for Defendants.

OPINION AND ORDER GRANTING PLAINTIFF'S MOTION TO REVERSE ADMINISTRATIVE DENIAL OF INSURANCE BENEFITS AND DENYING DEFENDANT'S MOTION TO AFFIRM ADMINISTRATOR'S DECISION

DAVID M. LAWSON, District Judge.

Kurt Jessen, a forty-four-year-old manager working for Hewlett Packard, died from a heroin overdose while on assignment for his employer in Melbourne, Australia. Hewlett Packard provided its employees with a life insurance policy underwritten by defendant Life Insurance Company of North America that paid benefits to a designated beneficiary in the event the employee dies as a result of an accident. Because the insurance policy was issued as part of an employee welfare benefit plan, it is governed by the Employee Retirement Income Security Act of 1974 (ERISA). See 29 U.S.C. § 1002(1)(A). Jessen's beneficiary was plaintiff Lisa Jessen, Kurt's wife of four months at the time of his death. She applied for the death benefit, which the defendant denied on the ground that Kurt's death was not an accident. After a round of administrative appeals, this lawsuit followed. The parties filed cross motions on the administrative record and the Court heard oral argument on April 19, 2010. The parties agree that the de novo standard of review applies. The administrative record is bereft of any evidence that Kurt Jessen intended to injure himself or that his death would result from his illicit drug use. Although Jessen's use of illicit drugs certainly amounts to risky behavior, there is no basis in the record to conclude that his death resulted from anything but an accident, and the evidence does not invoke any of the policy's exclusions. The defendant's denial of benefits violated the plan's language, and therefore the Court will grant the plaintiff s motion to reverse the plan administrator's decision and deny the defendant's motion to affirm it.

I.

Jessen's group life insurance policy procured by Hewlett Packard contained the following terms:

In exchange for the payment of premiums ..., we agree to pay benefits to all eligible persons (as defined in Schedule I):

a) who suffer injury to the body in any of the types of accidents described in Schedule IV, which happens while he is covered by this policy; and

b) who, as a direct result of the injuries, and from no other cause, suffered a covered loss (as defined in Description of Coverage).

AR 546. The benefits for loss of life are classified as “Coverage A” and are payable if “a) a person is injured by one of the types of accidents described in Schedule IV which happens while he is covered by this policy; and b) he suffers one of the losses listed below as a direct result of the injuries, and from no other cause, within a year of the accident.” AR 554. Schedule IV includes “any accident which occurs anywhere in the world while a covered person, on a business trip, is traveling or making a short stay: a) away from [the employer's] premises in his city of permanent assignment; and b) on business for [the employer], and in the course of [the employer's] business. All such trips must be authorized by [the employer.]” AR 557.

The parties agree that Jessen died while he was in Australia on a business trip for Hewlett Packard, and that the cause of death was a heroin overdose. Whether he died as a result of an “accident” is one point of contention in the case. In a footnote in its response brief, the defendant also maintains that Jessen took the drugs with the intention to overdose. The insurance policy excludes from coverage “benefits for loss caused by or resulting from ... [s]uicide, attempted suicide, or whenever a covered person injures himself on purpose, while sane or insane.” AR 555. However, the defendant did not cite that provision of the policy to support its denial of benefits at the administrative level. The policy also contains an exclusion of coverage for self-inflicted injuries, upon which the defendant relies; but the defendant did not cite that provision as a basis for denying benefits, either.

The parties also agree that the applicable plan language does not call for any level of deference to the plan administrator's decision, and that the applicable standard of review is de novo.

The facts of the case as disclosed by the administrative record are as follows. Kurt Jessen was employed as an operations manager for Hewlett Packard. He frequently traveled internationally and arrived in Melbourne on business on Saturday, April 26, 2008, to attend a business conference. He was scheduled to return to the United States within a week. When he was late for a business meeting on April 29, his colleague contacted the hotel where he was staying. The hotel's duty manager and security officer went up to Jessen's room, where they found him lying on the bathroom floor in a supine position, with his left sleeve rolled up, a “recent ven[i]puncture” on his left inner elbow, and a small amount of vomit “from airway and down side of face.” AR 464, 487, 518. On the bathroom counter top, the hotel employees found drug paraphernalia consisting of a small Sharps container, two syringes, some alcohol swabs, and a used plastic spoon. Also found in the hotel room were pills of Suboxone (medical substance used to treat an opiate addiction), Chantix (smoking cessation treatment), Imodium, and Tylenol.

According to the Inquest Brief of the Victoria police department prepared by Detective Leading Senior Constable Adrian Smith, the reason of Jessen's death was “[a]ccidental illicit drug overdose (heroin).” AR 452. Testing confirmed that Jessen had 0.2 mg/L of morphine in his blood, 3.7 mg/L of morphine in his urine (which usually indicates the use of heroin within six hours of death), and 0.03 mg/L of codeine in his blood. The autopsy report explained that “[m]orphine is the principal metabolite of heroin” and that “[c]odeine is often found as an impurity in heroin.” AR 52, 58. The autopsy revealed no evidence of significant natural disease and no signs of injury, but confirmed pulmonary edema, which also commonly occurs with overdose deaths.

There is little dispute that Jessen had a long history of drug dependence. His mother recalled that Jessen “began to experiment with drugs ... between 1990–1991, perhaps earlier,” had been admitted “in several inpatient short term and long term rehabilitation facilities,” and managed to be “drug free sporadically, for periods of from one to three years.” AR 65. One of Jessen's most recent relapses occurred when he resided in Melbourne in 2006–2007. His mother believed that he “befriended a woman [who] ... provided Kurt with drugs in exchange for a place to live.” AR 66. There is also testimony on the record that during his stay in Australia in 2006–07, Jessen, who at the time was separated from his second wife, dated one Sheila Margaret Scott. AR 508, 504. Scott recalls that Jessen got her hooked on heroin and tried to introduce her to other illicit drugs. See AR 509–10.

This relapse prompted both Jessen and Scott to enroll in the outpatient rapid detox program with Dr. Yona Josefsberg, where both were placed on the Suboxone program. Although Jessen's mother reports that Jessen had a brief, two- or three-day relapse during the course of the program, she insists that Jessen was drug-free following his return from Australia in August 2007.

Following his return from Australia in August 2007, Jessen met his third wife, Lisa M. Jessen, the plaintiff in the present case. After a month of dating, Jessen proposed, and the couple married on December 31, 2007. Jessen had two daughters from previous relationships; the plaintiff also had a daughter from a previous marriage. Jessen's mother claims that the plaintiff was Jessen's “soulmate” and “the love of [his] life.” AR 504. The plaintiff likewise recalls having a solid, loving relationship with Jessen; she also notes that Jessen treated her daughter Amanda as his own.

The plaintiff remembers that when Jessen was traveling, as he would frequently do for his work, he would contact her regularly during set times each day. The plaintiff recalls her last conversations with Jessen during his final trip to Melbourne:

4. Kurt left for Melbourne, Australia on April 20, 2008.

5. On April 24, 2008, Kurt called me in the air as he was leaving Germany on his way to Singapore. During this conversation, we discussed this trip being his last for a while so we could spend time together in our new married life. Kurt had already traveled two months out of the four months we had been married.

6. He called me on April 25, 2008 to tell me he was leaving Singapore for Australia.

7. He called me about 12:42 p.m. on April 26, 2008 as soon as his plane landed and got situated with his car and baggage. He told me he couldn't wait to come back home, that he missed me and my daughter and was sorry to be missing my birthday. He promised to get me an opal charm for my chain.

8. My mother called me on Sunday, April 27, 2008 to take me to lunch. Kurt called while I was at lunch and I told him I was with my mother and would call him after lunch. He didn't want to wait and wanted to talk to him at that moment. He became upset and short with me because I wouldn't talk to him. He had never acted this way with me before and was completely out of the ordinary for him. He kept calling me and I did not answer. I did call him after lunch and we argued about the earlier calls. He felt bad that he had missed Valentine's Day, Amanda's birthday and would be missing my birthday because of this trip.

9. My mother told me later that day that Kurt called her earlier to thank her for taking me to lunch and...