United States District Court, S.D. Texas, Galveston Division
MEMORANDUM OPINION AND ORDER
C. Hanks Jr. United States District Judge
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.
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. (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.
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.
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 and AD&D benefits (together,
“the Plan”). Mohedano designated his wife Sandra and
his brother Robert as the primary and contingent
Terms of the Plan
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.
“Additional Summary Plan Description Information,
” the Plan Administrator (here, Enterprise)
administers, and is the named fiduciary of the Plan.
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
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.
Candido Mohedano, Jr.'s Death
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.
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.
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
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
Unum's Denial of AD&D Benefits to ...