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UNUM Life Insurance Co. of America v. Mohedano

United States District Court, S.D. Texas, Galveston Division

February 23, 2017

SANDRA MOHEDANO, et al, Defendants.


          George C. Hanks Jr. United States District Judge

         This case stems from a dispute over the employee benefit account of Candido Paul Mohedano, Jr. Mohedano enrolled through his employer in both basic and supplemental life insurance and-at issue here-accidental death and dismemberment (“AD&D”) insurance. Plaintiff Unum Insurance Company of America (“Unum”) issued the policies.

         Mohedano died during an altercation with his wife and plan beneficiary, Sandra Mohedano. Unum filed a Complaint against Sandra, Robert Mohedano (decedent's brother), and Candido Paul Mohedano, Sr.[1] (together, “The Mohedanos”). Unum notified the Mohedanos that it was unable to approve the AD&D benefit. The Mohedanos filed an amended answer and counterclaim, seeking declaratory relief. Unum and the Mohedanos then each filed motions for summary judgment.

         For the reasons stated below, Unum's motion for summary judgment (Dkt. 47) will be granted and Mohedanos' motion for summary judgment (Dkt. 49) will be denied.

         I. Background

         The following summary of events is based on undisputed evidence contained in the administrative record. Candido Paul Mohedano, Jr. was employed by Enterprise Products Company (“Enterprise”). Enterprise participated in the Select Group Insurance Trust Policy No. 29200 (Transportation and Public Utilities Industry Fund), issued by Unum. Mohedano became eligible for several types of benefits under this policy through his employment with Enterprise. He enrolled for basic and supplemental life[2] and AD&D benefits (together, “the Plan”).[3] Mohedano designated his wife Sandra and his brother Robert as the primary and contingent beneficiaries, respectively.

         A. Terms of the Plan

         The Summary of Benefits cover page lists Maine as the governing jurisdiction. The “Accidental Death and Dismemberment Insurance Benefit Information” explains that beneficiaries “will receive payment when Unum approves your death claim providing you meet certain conditions.” Under the terms of the policy, “[t]he benefit will be paid only if an accidental bodily injury results in one or more of the covered losses [including loss of life].” Under “WHAT ACCIDENTAL LOSSES ARE NOT COVERED UNDER YOUR PLAN?, ” Unum states that the plan “does not cover any accidental losses caused by, contributed to by, or resulting from: . . . an attempt to commit or commission of a crime . . . [or] being intoxicated.” The Glossary defines the following terms:

ACCIDENTAL BODILY INJURY means bodily harm caused solely by external, violent and accidental means and not contributed to by any other cause.
INTOXICATED means that your blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state where the accident occurred.

         Under “Additional Summary Plan Description Information, ” the Plan Administrator (here, Enterprise) administers, and is the named fiduciary of the Plan.

         Enterprise has legal authority to delegate its duties. The insurer (here, Unum) administers the benefits, which are provided in accordance with the Summary of Benefits. Under “YOUR RIGHTS UNDER ERISA, ” the employee may appeal a denial of rights. Under “DISCRETIONARY ACTS, ” Enterprise delegates discretionary authority to Unum to:

[M]ake benefit determinations under the Plan. . . . Benefit determinations include determining eligibility for benefits and the amount of any benefits, resolving factual disputes, and interpreting and enforcing the provisions of the Plan. All benefit determinations must be reasonable and based on the terms of the Plan and the facts and circumstances of each claim.
Once you are deemed to have exhausted your appeal rights under the Plan, you have the right to seek court review under Section 502(a) of ERISA of any benefit determinations with which you agree. The court will determine the standard of review it will apply in evaluating those decisions.

         B. Candido Mohedano, Jr.'s Death

         On September 7, 2013, Sandra Mohedano shot and killed her husband Candido Mohedano, Jr. The shooting occurred after Candido, Sandra, and Candido's brother Bill had returned home from drinking at a karaoke lounge. Sandra was charged with murder. The trial was held in the 122nd Judicial District Court of Galveston County, Texas.

         Sandra testified about a history of abuse at the hands of Candido. According to Sandra, she and Candido began to argue in the car on the night of the shooting. She testified to the following: 1) he violently attacked her once they pulled into the driveway; 2) she ran into the home, grabbed the shotgun, and warned the approaching Candido to stop; 3) Candido told her, “You're dead now, bitch, ” and continued approaching; and 4) the shotgun accidentally discharged. Candido died from a single shot to the chest.

         Bill sat in the back seat of the car when the shooting occurred. He testified to the following: 1) there was no argument on the way home, but that Sandra began attacking Candido in the driveway; 2) she threatened to kill both Candido and Bill before running inside; 3) she grabbed the shotgun with one hand and confronted Candido; and 4) she then shot and killed him.

         In addition to the testimony of Sandra and Bill, the jurors heard from the 911 dispatcher, law enforcement and medical first responders, the investigators, and medical and laboratory personnel. The doctor performing the autopsy testified that Candido's blood sample contained an alcohol content of .217 grams percent, almost three times the legal driving limit in Texas. The jury returned a ‘not guilty' verdict.

         C. Unum's Denial of AD&D Benefits to ...

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