The opinion of the court was delivered by: MAROVICH
Plaintiff Pamela Hertel Mers ("Mers") asserts that Defendant Marriott International Group Accidental Death and Dismemberment Plan (the "Plan") wrongfully denied her claim for benefits under the Plan's Business Travel Accident Insurance Policy, in which Mers' deceased husband, Dale Mers, was enrolled. Accordingly, in Count I of her Complaint, Mers seeks payment of those benefits from the Plan pursuant to Section 502(a)(1)(B) of the Employee Retirement Security Income Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B).
Now before the Court are the parties' cross-motions for summary judgment. For the reasons set forth below, the Court grants the Plan's, and denies Mers', summary judgment motion.
The following facts, taken from the parties Local Rule 12(M) and 12(N) statements, are largely undisputed by the parties. The Plan is a welfare-benefit plan provided by Marriott for its employees; the Plan is subject to, and governed by, ERISA. The Plan offers Marriott employees two types of accidental death insurance policies: (1) a Business Travel Accident policy (the "BTA Policy") that provides protection for death or dismemberment resulting from an accident while an employee is travelling on company business; and (2) an Optional 24-Hour Policy (the "24-Hour Policy") that provides round-the-clock protection for death or dismemberment resulting from an accident, regardless of whether the employee is travelling on company business at the time of his or her injury.
All full-time Marriott employees automatically are enrolled in the BTA Policy--those employees earning $ 30,000 or more per year being eligible for up to $ 100,000 in benefits, and those employees earning less than $ 30,000 per year being eligible for up to $ 50,000 in benefits. Enrollment in the 24-Hour Policy is not automatic, however; interested employees must authorize premium deductions from their paychecks in order to obtain coverage.
Dale Mers was employed by Marriott as a Director of National Accounts. As a full-time Marriott employee earring more than $ 30,000 a year, Dale Mers was enrolled automatically in the BTA Policy and was eligible for up to $ 100,000 in benefits under that policy. Dale Mers also enrolled in the 24-Hour Policy for up to $ 100,000 in benefits; premiums for the 24-Hour Policy were regularly deducted from Dale Mers' paycheck. Mers was her husband's designated beneficiary.
On January 5, 1994, Dale Mers checked into a Chicago hotel to attend a five-day conference of the Professional Convention Management Association ("PCMA"). Dale Mers' PCMA dues were paid by Marriott and his involvement in the organization and attendance at the conference were undertaken in furtherance of Marriott's business. As part of the PCMA conference, Dale Mers participated in a Habitat for Humanity project on January 5, using a sledge hammer and crow-bar to tear down a plaster and lath wall. While engaged in this strenuous activity, Dale Mers collapsed. He died the next day, January 6, 1994, at St. Francis Hospital. Dale Mers' death certificate lists the cause of death as cardiac arrest due to, or as a consequence of, cerebral hemorrhage; no autopsy was performed. At the time of his death, Dale Mers was 44 years old, was feeling well, and, other than suffering from mild, non-insulin diabetes, was in good physical health.
Soon after Dale Mers' death, Mers was told by Marriott that her husband possessed only $ 100,000 in accidental death coverage. Mers, allegedly unaware that her husband had enrolled in the 24-Hour Policy, assumed this $ 100,000 coverage to be under the BTA Policy.
On or about March 2 1994, Mers, following the procedures set forth in the Summary Plan Description, filed a claim for benefits with Marriott. Marriott apparently delegated responsibility for resolving factual questions and determining Mers' eligibility for Plan benefits to AIC (a subsidiary of AIG, the Plan's insurer), who, in turn, retained the services of Equifax, a claims service.
In submitting Mers' claim to the Plan, Marriott included only a copy of Dale Mers' enrollment form for the 24-Hour Policy. Marriott errantly failed to notify the Plan of Dale Mers' enrollment in the BTA Policy and did not file a formal claim with the Plan for BTA Policy benefits. Thus, in evaluating Mers' claim for benefits, the Plan considered only the terms of the 24-Hour Policy; the Plan did not realize that Mers had a potential claim for benefits under the BTA Policy.
On August 3, 1994, AIC wrote Per K. Hanson ("Hanson"), Mers' attorney, and advised him that, based upon its investigation of the circumstances surrounding Dale Mers' death, its review of Dale Mers' medical records, and its receipt of the medical opinions of Drs. Daniel Hier, M.D. and Jack Harnes, M.D., AIC had concluded that Mers was ineligible for benefits under the terms of the Plan. Specifically, AIC informed Hanson that, "In so far [sic] as Mr. Mers' exertion exacerbated a pre-existing condition [an intracranial aneurysm], we must conclude that Mr. Mers' death was not independent of all other causes of loss." (Ex. 7, Def. 12(M) Statement, p. 2.)
Mers appealed the Plan's denial and submitted for the Appeals Committee's consideration a September 16, 1994 letter from Dr. Allan B. Aven, M.D., S.C., who stated as follows:
This individual performed a series of extremely physically demanding activities during which increased vascular pressures were transmitted from the abdomen and chest into the vascular system of the brain (a Valsalva maneuver). This may have caused a blood vessel, previously weakened (by cholesterol plaque or congenital dysplasia) to rupture. On the other hand, had this person continued in his usual and customary lifestyle, the vascular rupture would not have suddenly happened.
(Ex. 4, Def. 12(M) Statement, p. 1.) AIC forwarded Dr. Aven's letter to Dr. Harnes, AIC's medical consultant, for review. Dr. Harnes reported back to AIC that, "Dr. Aven argues that a pre-existing condition, aggravated by exertion, caused [Dale Mers'] hemorrhage. Since the hemorrhage would thus not be independent of the pre-existing disease hypothesized by Dr. Aven, I fail to see why his letter should change our position." (Ex. 12, Def. 12(M) Statement.)
Based upon its review of the full administrative record, the Appeals Committee re-affirmed the denial of benefits to Mers under the 24-Hour Policy. Mers was informed on the Appeals Committee's decision by letter dated December 8, 1994.
Mers filed her Complaint with this Court on December 22, 1995. After much initial confusion, both parties now agree that Mers' Count I seeks payment of benefits only under the BTA Policy. On August 29, 1996, the Plan filed its motion for summary judgment, asserting that (1) Mers' claim is premature, as she failed to exhaust her administrative remedies by filing a claim under the BTA Policy with the Plan; or, alternatively, (2) because the Plan's determination that Dale Mers' death did not result independently of all other causes of loss was not "downright unreasonable," the Plan's denial of benefits must be affirmed, as a matter of law, using the deferential, "abuse of discretion" standard of review. On September 26, 1996, Mers filed her motion for summary judgment, contending that (1) given AIC's inherent conflict of interest in evaluating Mers' claim for benefits, the Plan's denial must be reviewed de novo, rather than under an "arbitrary and capricious" standard; and (2) because Dale Mers' death was caused by his unusually strenuous work activity at the Habitat for Humanity project and was wholly unexpected and unforeseeable, his death constitutes an "accident" within the meaning of the BTA Policy--an accident for which she is entitled, as a matter of law, to payment of benefits.
A. Standards for Summary Judgment
Summary judgment is appropriate where the pleadings, answers to interrogatories, admissions, affidavits, and other materials show that there is "no genuine issue as to any material fact," and the moving party is entitled to judgment as a matter of law. Fed. R. Civ. P. 56(c). Only genuine disputes over "material facts" can prevent a grant of summary judgment. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 91 L. Ed. 2d 202, 106 S. Ct. 2505 (1986). "Material facts" are those that might affect the outcome of the suit under governing law. Id. A "genuine issue" exists if there is "sufficient evidence favoring the non-moving party for a jury to return a verdict for that party." Id. at 249. When considering a motion for summary judgment, the Court must view the facts, and all the inferences drawn from those facts, in the light most favorable to the nonmovant. Griffin v. Thomas, 929 F.2d 1210, 1212 (7th Cir. 1991); Roman v. U.S. Postal Service, 821 F.2d 382, 385 (7th Cir. 1987).
B. Mers' Failure To Exhaust Her Administrative Remedies
The parties agree that Mers has failed to exhaust her administrative remedies, as Mers (through circumstances arguably beyond her control) never has presented her claim for benefits under the BTA Policy to the Plan fiduciaries and/or administrator for consideration. Exhaustion of administrative remedies prior to filing suit generally is required because it (1) "enhances the ability of plan fiduciaries to expertly and efficiently manage their plans by preventing premature judicial intervention," Powell v. AT&T Comm., Inc., 938 F.2d 823, 826 (7th Cir. 1991); (2) assists the courts by ensuring that a plaintiff's claims have been "fully considered" by plan fiduciaries, Id.; and (3) "gives effect to Congress' apparent intent, in mandating internal claims procedures, to minimize the number of frivolous lawsuits, to promote consistent treatment of claims, to provide a nonadversarial dispute resolution process, and to decrease the cost and time of claims settlement." Wilczynski v. Lumbermens Mutual Cas. Co., 93 F.3d 397, 402 (7th Cir. 1996). Consequently, the Seventh Circuit has made clear that "application of the exhaustion doctrine . . . is a matter within the discretion of the trial court," and that "as a matter of sound policy [the court] should usually [apply it]." Kross v. Western Elec. Co., Inc., 701 F.2d 1238, 1244-45 (7th Cir. 1983). Yet, courts should not, and generally will not, invoke the ...