United States District Court, E.D. Kentucky, Central Division, Lexington
HAROLD MILES, Personally and as Administrator for the Estate of TERRY MILES, Plaintiff,
FEDERAL INSURANCE COMPANY, Defendant.
MEMORANDUM OPINION AND ORDER
K. CALDWELL, CHIEF JUDGE.
Federal Insurance Company moved to dismiss certain claims
contained in plaintiff Harold Miles' Complaint (DE 1) for
failure to state a claim upon which relief can be granted.
(DE 11). For the following reasons, the motion is GRANTED.
Before entering a dismissal order, the Court will permit
Miles an opportunity to amend the complaint within fourteen
(14) days of this order.
October 22, 2013, Terry Miles died of accidental positional
asphyxia, or “accidental suffocation, ” an
unintended consequence of what was not the first time Terry
engaged in asphyxiation-inducing activities to derive
pleasure. (Compl. ¶¶ 14, 25, 29). At the time of
Terry's death, his father Harold Miles was a participant
in the Voluntary Accident Insurance Program Issued for Toyota
Engineering & Manufacturing North America, Inc.
(“the Policy”), a part of the Toyota Engineering
& Manufacturing Health and Welfare Benefit Plan
(“the Plan”). (Compl. ¶¶ 53-55; DE
11-2). Miles was the Primary Insured Person and
beneficiary of the Policy, which Federal underwrote, issued,
and administered. (Compl. ¶¶ 8, 10-12). Terry was a
dependent entitled to coverage under the Plan and Policy.
(Compl. ¶ 12).
Subject to all the terms and conditions of this policy and
the payment of premium, We will provide the following
Accidental Death and Dismemberment
We will pay the applicable Benefit Amount, shown in Section
IV-B of the Schedule of Benefits, if an Accident results in a
covered Loss not otherwise excluded. The Accident must result
from an insured Hazard and occur while an Insured Person is
insured under this policy, while it is in force. The covered
Loss must occur within one (1) year after the Accident.
Ex. 2, at 1-2) (capitalization and emphasis in original). The
Policy placed limits on what it would cover, excluding
“any Accident, Accidental Bodily Injury, or Loss caused
by or resulting from, directly or indirectly, an Insured
Person's suicide, attempted suicide or intentionally
self-inflicted injury.” (Compl. Ex. 2, at 2).
Terry's death, Miles submitted a claim to Federal under
the Plan and Policy seeking to recover benefits. (Compl.
¶ 18-19). Federal denied the claim. In the May 19, 2014
letter denying Miles' claim, Federal, through its
adjuster, Crawford U.S. Property & Casualty, stated that
the policy requirements for coverage for accidental loss of
life were not satisfied because Terry's death “was
the result of his voluntarily placing a cord around his
neck.” (Compl. Ex. 2, at 2). The letter continued:
This was confirmed by the received death certificate which
confirmed [Terry's] death was due to suffocation from a
cord around his neck and conversation with Coroner John P.
Goble. . . . While we recognize that [Terry's] death
certificate states that his death was an accident, even if we
were to assume (solely for the purposes of this analysis)
that this deduction is plausible, we fail to see how such
circumstances demonstrate that an Accident [as defined in the
Policy] caused an accidental death, since it has been
confirmed that the placing of the cord around his neck by
[Terry] was voluntary, which is not the direct result of an
Accident or Accidental Bodily Injury.
(Compl. Ex. 2, at 2-3).
appealed the denial on July 11, 2014, (Compl. ¶ 19), and
Federal once again denied Miles' benefits two months
later, reaffirming its decision that Terry's death was
not an accident as defined in the Policy and that the Suicide
or Intentional Injury exclusion precluded any coverage for
Miles' claim. (Compl. Ex. 5). Miles filed a second
“voluntary” appeal, in which he included a
written statement from John Goble, the Scott County Coroner,
indicating that Terry's death was accidental. (Compl.
¶ 20-21). The stated purpose of the letter was to
“clarify and correct the misunderstanding and
misinformation contained in the May 19, 2014 [Insurance
Denial] letter.” (Compl. ¶ 20). Federal did not
respond to Miles' “voluntary” appeal. (Compl.
now seeks relief from this Court pursuant to the Employee
Retirement Income Security Act, 29 U.S.C. § 1001 et seq.
(“ERISA”) for what he claims is a wrongful denial
of benefits under the Policy, an ERISA welfare benefit
program. Miles' complaint asserts various claims under
ERISA; one as a claim for benefits under ERISA §
502(a)(1)(B) styled as “breach of contract, ”
(Compl. ¶¶ 46-51) and others under § Section