In Alexandre v. National Union Fire Insurance Company, 22 F.4^th 261 (1^st Cir. 2022), the First Circuit Court of Appeals upheld National Union’s determination that an insured’s death was by suicide.

Alexandre was a participant in a group accident insurance plan provided by her employer. The plan was funded by a policy issued by National Union, which also administered claims. The plan was governed by ERISA.

Alexandre’s husband died after falling nine stories from the interior of a hotel. Alexandre sought payment of accidental death benefits in the amount of $500,000. National Union denied the claim on the grounds that the husband’s death was a suicide, which was an exclusion contained in the policy. Alexandre brought suit.

The district court upheld National Union’s decision and entered summary judgment in its favor. Alexandre then appealed.

The First Circuit first held that National Union’s decision would be reviewed under the arbitrary and capricious standard of review. With regard to the applicable law, the court rejected Alexandre’s argument that, because the case was transferred from the U. S. District Court in Florida, 11^th Circuit law should control. The court noted its previous rulings that when a district court transfers a case, the norm is that the transferring court applies its own Circuit’s cases on the meaning of federal law.

With regard to the merits of the claim, National Union had concluded that the incident occurred as related in the police investigation conducted of the death, which described the husband’s volitional and purposeful conduct as sprinting out of the hotel room and hurling himself over the tenth floor railing of the hotel. The court held that this conclusion was not arbitrary or capricious given that the summary was authored by a state official in the exercise of official duties and included the medical examiner’s investigation and interviews with two witnesses. Additional evidence included the death certificate which ruled the death as a suicide.

The First Circuit affirmed the district court’s decision in favor of National Union.

In N.R. v. Raytheon Company, 24 F.4^th 740 (1^st Cir. 2022), the First Circuit Court of Appeals reversed a district court’s dismissal of a Complaint alleging a violation of the Mental Health Parity and Addiction Equity Act (“Parity Act”).

N.R., a juvenile, received speech therapy related to his Autism Spectrum Disorder. N.R. and his family were covered by a health plan provided by Raytheon Company, which was administered by United Healthcare. The plan is governed by ERISA. United Healthcare denied the speech therapy claim based upon its interpretation of the exclusions contained in the benefit plan. N.R. brought suit.

The district court allowed the defendants' motion to dismiss the complaint and N.R. appealed to the First Circuit.

The district court dismissed the complaint because it agreed with the defendants’ representation of how the benefit plan works. The First Circuit held that, on a motion to dismiss, the district court’s determination was premature. The court found that the Complaint adequately alleged a violation of the Parity Act and therefore should be reinstated. The court also reinstated the claim for ERISA benefits pursuant to 29 U.S.C. §1132(a)(1)(B).

The court also held that the district court erred by dismissing the claim alleging Raytheon failed to respond adequately to a request for information pursuant to 29 U.S.C. §1132(a)(1)(A). The defendants argued that the claim failed because N.R. did not make the information request to the individual named as plan administrator. The court found that to be a “persnickety reading of the statute” and held that N.R.’s attempt to obtain the information by contacting Raytheon (the named administrator’s employer), Raytheon’s in-house counsel and Raytheon’s outside counsel was sufficient.

The court did dismiss the claim for breach of fiduciary duty pursuant to 29 U.S.C. §1132(a)(2) because that provision of ERISA is concerned solely with plan asset mismanagement and solely authorizes remedies that inure to the benefit of the ERISA plan as a whole. Given the Complaint’s failure to allege such relief, the court found that claim was properly dismissed.

In Ashe v. Shawmut Woodworking & Supply, Inc., 489 Mass. 529 (2022), the Supreme Judicial Court of Massachusetts was asked to decide whether a party whose mental or physical condition was an issue in a case could be required, pursuant to Massachusetts Rule of Civil Procedure 35, to appear for an examination before a neuropsychologist. The court answered Yes.

In connection with a civil lawsuit, the defendant had requested the plaintiff submit to a neuropsychological examination by a board-certified clinical neuropsychologist. Rule 35 allows a court to order a party to submit “to a physical or mental examination by a physician . . .” The plaintiff argued that because the neuropsychologist was not a physician, he should not be required to appear for the examination.

The court stated that because “physician” was not defined in the rule, it may look to its “usual and accepted meaning”, provided that it was consistent with the purpose of the rule. The court first looked at the dictionary definition of “physician” which was a “person skilled in the art of healing” or a “doctor of medicine.” Finding that neuropsychologists conduct assessments to evaluate, diagnose and treat individuals with known or suspected neurological diseases or injuries, the court held that although neuropsychologists are not medical doctors, they are skilled in the art of healing and therefore a physician pursuant to that definition of the word.

The court also noted that in considering the meaning of “physician” as used in the rule, it was incumbent on the court to interpret the rules of civil procedure in a manner which accomplishes their obvious purpose and objective. Because the purpose of Rule 35 is to provide a defendant with an equal opportunity to evaluate any injuries the defendant is alleged to have caused, and the plaintiff was relying, in part, on a report from another neuropsychologist, the court said it was obvious that the defendant may invoke Rule 35 to give themselves an opportunity to have their own neuropsychologist examine the plaintiff.

In a footnote, the court stated that it was asking a standing advisory committee on the rules of civil procedure to consider whether an amendment or other guidance on the rule was in order.

The decision is also noteworthy for life insurers because the Massachusetts Appeals Court previously interpreted Massachusetts General Law c.175, §124, which governs recissions of life insurance policies, to require the medical examination referred to in §124 be performed by a physician, not a nurse. See Robinson v. Prudential Ins. Co., 56 Mass. App. Ct. 244 (2002). In that case, the court construed the term “medical examination” as contained in the statute. The court referred to Ballantine’s Law Dictionary’s definition of medical examination which was an examination of a person by a “physician”, and that a nurse was not a physician. Query whether this new SJC decision opens the door for the argument that a medical examination by a nurse should also be considered as one conducted by a physician.

In Rain v. Connecticut General Corporation, 2022 WL 2294061 (D. Mass. 2022), the U.S. District Court of Massachusetts allowed a motion for protective order prohibiting the deposition of one of Connecticut General’s in-house counsel, at least for now.

The motion was denied without prejudice for Rain to file a subsequent motion if she can make a showing that complied with the court’s ruling.

In Sevelitte v. The Guardian Life Insurance Company of America, 2022 WL 1051351 (D. Mass. 2022), the U.S. District Court of Massachusetts held that the divorced spouse of the deceased was not entitled to the proceeds of a life insurance policy. The court also entered a judgment in favor of Guardian Life and awarded it attorney’s fees.

Joseph Sevelitte purchased a life insurance policy in 1986. It named his then wife, Renee, as beneficiary. There was no contingent beneficiary. In 2013, Joseph and Renee divorced, and he later married Robyn. Joseph died in 2020.

A dispute arose regarding who was entitled to the proceeds of the policy. While Guardian was attempting to resolve the dispute, Renee filed suit in state court bringing multiple claims against Guardian. Guardian removed the case to federal court, added Robyn as a party, and brought a counterclaim for interpleader. The parties then brought dispositive motions.

On the merits of who was entitled to the proceeds, the court ruled in favor of Robyn, based primarily on the application of Massachusetts General Law, c. 190B, §2-804. That statute, which was specifically addressed by the Supreme Judicial Court in American Life Assurance Company of Columbus v. Parker, 488 Mass. 801 (2022), operates as a revocation of the designation of a spouse as a beneficiary in a life insurance policy after a divorce, unless there is an express agreement that the designation continue. While Renee made multiple arguments to establish such a designation, the court rejected them. Regarding Guardian, the court dismissed Renee’s multiple claims, including breach of contract and violations of Chapter 93A. The court also made an express order enjoining Renee and Robyn from commencing or prosecuting any claim against Guardian in state or federal court regarding the policy.

Finally, the court awarded attorney’s fees to Guardian for its time spent on the interpleader. While noting that additional time was required to be spent by Guardian in addressing Renee’s claims against the company, the court applied the “American Rule” which holds that each

party must bear its own legal fees.

In MacNaughton v. Paul Revere Life Insurance Company, 2022 WL 780724 (D. Mass. 2022), the U.S. District Court of Massachusetts agreed with Paul Revere that the insertion of discretionary language in the application for insurance, which was made part of the group policy, and in the summary plan description were sufficient to grant discretion to Paul Revere. However, the court remanded the claim to Paul Revere on the grounds that MacNaughton was prejudiced by not receiving medical reviews conducted by Paul Revere during the administrative appeal.

MacNaughton was a radiologist who had stopped working in 2007 due to an eye condition. She was paid benefits for 10 years until an independent medical examination determined that her vision would allow her to perform the duties of a radiologist.

Shortly after benefits were discontinued, MacNaughton requested a copy of her claim file. It was promptly provided. During the appeal, MacNaughton submitted new medical information, which was reviewed by Paul Revere’s medical consultant. Paul Revere upheld its decision discontinuing benefits. After receiving the determination, MacNaughton again requested a copy of the claim file. Again, it was promptly provided. She then filed suit.

On cross-motions for summary judgment, the court first determined the standard of review. Noting that the plan documents contained specific language that the contract consisted of not only the group policy, but also the application for the policy, the court found that the application, which contained language giving Paul Revere discretionary authority over claim determinations, was appropriate. Similar language was contained in the summary plan description.

MacNaughton argued that de novo review should be applied because she was not given a copy of either the application or the SPD. The court rejected the argument noting that both documents would have been available to MacNaughton, who was not only an employee of the group but also a part owner.

The court next addressed MacNaughton’s argument that she was not given a full and fair review because Paul Revere did not disclose the medical opinions generated on appeal until after the appeal decision was reached. MacNaughton first raised this argument in her motion for summary judgment relying on the First Circuit’s recent decision in Jette v. United of Omaha Life Ins. Co., 18 F.4^th 18 (1^st Cir. 2021). The claim was governed by the “old”, pre-April 2018, Department of Labor claim regulations. Those regulations require that Paul Revere provide documents related to the claim “upon request.” Despite the fact that MacNaughton was provided with the claim file promptly after each of her two requests, the court, relying on the request made by MacNaughton after the claim was initially denied, held Paul Revere was also required to disclose information generated on appeal despite the fact that no ongoing request was made by MacNaughton.

Because the court found that MacNaughton was prejudiced by not having access to the medical reviews on appeal, it remanded the case to Paul Revere.