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Woolums v. Hawkins

September 8, 2006

ADAM T. WOOLUMS, PLAINTIFF,
v.
RAY HAWKINS, ET AL. DEFENDANTS.



The opinion of the court was delivered by: Jeanne E. Scott, U.S. District Judge

OPINION

This matter comes before the Court on the Defendants' Joint Motion for Summary Judgment (d/e 9) (Summary Judgment Motion). Plaintiff Adam Woolums suffered injuries in an automobile accident. Woolums was driving the vehicle while intoxicated at the time of the accident. Woolums sought medical benefits from the Operating Engineers Local 965 Health Benefit Plan (Plan). The Plan is an ERISA qualified plan. Defendants Ray Hawkins, David Mifflin, Robert Bruner, Joe Klein and Mike Zahn are the Trustees of the Plan (Trustees). The Plan Administrator denied Woolums' claim because it determined that driving while intoxicated was an illegal occupation and because the injuries were self-inflicted. The Plan excluded payment of benefits for injuries arising from an illegal occupation and for self-inflicted injuries. On review, the Defendants decided that driving while intoxicated was an illegal occupation, but they did not consider whether the injuries were self-inflicted.

The Court notified the parties that it intended to consider whether summary judgment should be entered in favor of Woolums and gave the parties the opportunity to file any additional materials. Text Order entered August 18, 2006. For the reasons set forth below, the Court has determined that the Trustees' actions were arbitrary and capricious when they decided that driving while intoxicated was an illegal occupation. The Court enters judgment in favor of Woolums on this issue. The Trustees, however, never considered whether Woolums' claim was excluded because his injuries were self-inflicted. The Court, therefore, remands the case to the Plan for a review by the Trustees of the Plan for a determination whether Woolums' injuries were self-inflicted.

STATEMENT OF FACTS

On September 1, 2001, Woolums was seriously injured while driving a motor vehicle while intoxicated. He has been permanently disabled as a result of this accident. Woolums was entitled to medical benefits under the Plan. The Plan is an ERISA qualified plan. Woolums submitted his medical bills to the Plan for payment. On June 28, 2002, a representative of the Plan, Lisa Frasco, sent Woolums a letter which stated, in part:

After a careful review of the information that you provided to this office, the claims related to the traffic accident on September 1,2001 have been denied. The Summary Plan Description (SPD) states in pertinent part that benefits will not be paid for the following injuries:

1. Self-inflicted injuries (See SPD dated August 1995, page 39); or

2. Injuries for which a contributing cause was such person's being engaged in an illegal occupation (See SPD dated August 1995, page 40). Occupation is an activity in which one engages.

The information submitted by you indicates that a contributing cause of the accident was that you voluntarily drove a motor vehicle while under the influence of alcohol and illegal substances. Any injuries sustained as a result of such voluntary acts are considered self-inflicted.

Summary Judgment Motion, Exhibit E. The SPD stated:

The following exclusions and general limitations apply to all benefits provided by the Operating Engineers Local No. 965 Health Benefit Plan unless specifically waived or modified by a particular benefit section. . . . .

Self-Inflicted Injury or Substance Abuse Payment will not be made for self-inflicted injury . . . .

Illegal Occupation or Commission of Felony

The Trustees will not be liable for loss . . . to which a contributing cause was such person's being ...


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