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Cultrona v Nationwide Life Insurance Company

Case No. 13-3558 (C.A. 6, Apr. 9, 2014)

Nicole Cultrona filed suit against Nationwide Life Insurance Company (Nationwide), the Nationwide Death Benefit Plan (the Plan), the Nationwide Benefits Administrative Committee (the BAC), and StarLine Group (StarLine) following the denial of her claim for accidental-death benefits and her subsequent exhaustion of the Plan’s internal administrative procedures. The claim was based on the death of Nicole’s husband, Shawn Cultrona, in June 2011. Nicole, an employee of a Nationwide affiliate, was a participant in the Plan. Among other benefits, the Plan provided coverage in the event of an accidental death. Shawn was a covered person under the Plan, and Nicole was the designated beneficiary for any benefits paid as a result of Shawn’s death. Following the parties’ cross-motions for judgment on the administrative record, the district court entered judgment in favor of the defendants, but assessed a statutory penalty of $55 per day (for a total of $8,910) against the BAC for its delay in providing Nicole with a copy of the accidental-death policy after her written request for relevant documents.

Nicole argues that the denial of her claim was arbitrary and capricious. On the other hand, the BAC (on behalf of itself and the other defendants) asks us to affirm the judgment in its favor, but separately contends that the district court erred in the imposition of a penalty against the BAC as the Plan administrator. For the reasons set forth below, we AFFIRM the judgment of the district court in all respects.

I. BACKGROUND



Benefits are payable under the Plan if a covered person suffers an “injury” as a result of an “accident.” An accident is defined in the policy as “an unintended or unforeseeable event or occurrence which happens suddenly and violently.” But not every accident is covered under the Plan. One of the Plan’s exclusions, Exclusion 12, provides that no benefits will be paid if the “Covered Person [is] deemed and presumed, under the law of the locale in which the Injury is sustained, to be under the influence of alcohol or intoxicating liquors.” (emphasis in original).
 

 

Judge(s): Ronald Lee Gilman
Jurisdiction: U.S. Court of Appeals, Sixth Circuit
Related Categories: Administrative Law , Criminal Justice , Employment , Expert Witness , Health Care , Insurance , Transportation
 
Circuit Court Judge(s)
Deborah Cook
Ronald Gilman
David McKeague

 
Trial Court Judge(s)
Sara Lioi

 
Appellant Lawyer(s) Appellant Law Firm(s)
Kelly Lawrence Frantz Ward LLP
Mark Rodio Frantz Ward LLP
Michael Smith Frantz Ward LLP

 
Appellee Lawyer(s) Appellee Law Firm(s)
Lisa Kathumbi Littler Mendelson PC
Daniel Srsic Littler Mendelson PC

 

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Click the maroon box above for a formatted PDF of the decision.
policies) (internal quotation marks omitted). moreover, the bac charter requires a consultation nationwide benefits administrative committee (the bac), and starline group (starline) vargo v. travelers ins. co., 516 n.e.2d 226, 229 (ohio 1987) (explaining that the coroner is of the amendment, not the underlying policy. see cultrona, 936 f. supp. 2d at 855 n.15 (citing the policy in question. section 1132(c) commits the amount of the penalty to the district court’s accord that neither prejudice nor injury are prerequisites to recovery under the penalty provisions awarding nicole $55 per day (for a total of $8,910) as a statutory penalty for the bac’s failure in the hours before he died, had been out drinking with friends and was seen nationwide provided notice of amendment no. 1 . . . and all documents comprising the defendants-appellees, nicole argues that the denial of her claim was arbitrary and capricious. on the other intoxication . . . accident: prolonged and extreme hypertension of neck and torso while formulated.”). nicole’s counsel, true enough, broadly phrased the request as one for “all sound discretion. see 29 u.s.c. § 1132(c)(1) (explaining that the court may, in its discretion, revised code (orc) § 4511.19, which prohibits operating a motor vehicle while intoxicated. became unconscious while intoxicated (passed out) [and] . . . [t]he county of the parties subsequently filed cross-motions for judgment on the administrative record. beneficiary for any benefits paid as a result of shawn’s death. following the parties’ claim. moreover, the administrative record reflects that the request was sufficiently clear for a nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 12 documents comprising the administrative record and/or supporting nationwide’s decision.” > although nicole argues that she did suffer prejudice as a result of the bac’s failure to group, _________________ in the bac’s argument and thus adopt the standard on a going-forward basis. as summarized in ethanol intoxication.” nicole then filed suit in federal court, asserting claims under the argued: march 19, 2014 in particular, she asserts that (1) the bac did not carry its burden of proving that exclusion 12 defendant-appellee/cross-appellant. │ nicole’s attorney responded to the second denial letter the next day, simultaneously │ breach-of-fiduciary-duty claim against nationwide, the plan, the bac, and starline. her the evidence of this exchange contained in the administrative record). after extensive briefing, the district court entered judgment in favor of the defendants. see nicole’s attorney responded to starline’s denial letter by calling the denial “completely the denial shall prevail. as noted in the original letter, this plan of insurance is 29 u.s.c. § 1132(c)(1)(b); 29 c.f.r. § 2575.502c-1; see also minadeo v. ici paints, 398 f.3d level at which ohio presumes intoxication as a matter of law; the loss is precluded appealing the denial and requesting “all documents that you contend prove that nationwide the clear-notice standard strikes a reasonable balance between a claimant’s right to exclusion 12 as follows: decision was arbitrary or capricious.” cook v. prudential ins. co. of am., 494 f. app’x 599, 604 nos. 13-3558/3585 for the sixth circuit the bac as the plan administrator. for the reasons set forth below, we affirm the judgment plan.”) (internal quotation marks omitted) (alteration in original). argument that the phrase “law of the locale” cannot mean ohio state law is without merit. v. nicole offers several arguments in support of her contention that the bac acted ohio, for appellees in 13-3585 and appellee-cross-appellant in 13-3585. on these facts given shawn cultrona’s acute ethanol intoxication at the time of f.3d 878, 880 (6th cir. 2007) (holding that the denial of benefits was arbitrary and capricious the next day. in the autopsy report, the examining pathologist concluded that the cause of death although such language would not pass the clear-notice test for most of the documents identified 1 otherwise general request.”). accordingly, we reject the bac’s argument that the district court following the denial of her claim for accidental-death benefits and her subsequent exhaustion of │ of fact in erisa cases are “subject to a clearly erroneous standard of review”). denial letter was “hardly a model of clarity”). the basic rationale for denying nicole’s claim— opposite conclusion—that the phrase “law of the locale” means state law. see republic administrator in this case had discretion to interpret the plan, the denial of benefits is reviewed in 29 u.s.c. § 1024(b)(4), one is hard-pressed to believe that the bac should not have known arbitrarily and capriciously in denying her claim. first, she argues that the bac was operating argued: kelly s. lawrence, frantz ward llp, cleveland, ohio, for appellant/cross- iii. conclusion timely receive plan-related documents upon request and the civil penalties facing plan nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 6 district court explained, however, the erisa regulations relied on by nicole for this argument to interviews they conducted, shawn cultrona had a history of alcohol abuse and, ‘driving or operating a motor vehicle’ . . . plan documents, so nationwide must have been meant something other than ohio state law when exclusion 12.” the response explained that the version of exclusion 12 cited in the denial letter ‘exclusions’ on page 18 of the policy is amended to remove the reference to “it is also hereby noted and agreed that exclusion #12 as found under section x – or more of the above documents within 30 days, then the district court may in its discretion intoxicated under orc § 313.19, which provides that the “cause of death and the manner and imposing the statutory penalty in question. for one thing, the district court did not err by accompanying findings of fact under the clear-error standard. see bartling v. fruehauf corp., decided and filed: april 9, 2014 appellee. daniel w. srsic, littler mendelson, p.c., columbus, ohio, for appellees in 433 (e.d. tenn. 1976) (same). cook, 494 f. app’x at 608 (affirming the denial of benefits even though the plan administrator’s but even if we assume that starline was referring to orc § 4511.19 in its denial letter, │ surrounding circumstances or the information being requested may require a response to an 751, 757 (6th cir. 2005) (“congress’ purpose in enacting the erisa disclosure provisions was but a conflict of interest, standing alone, does not require reversal. judge v. metro. life free to place the burden of clarity squarely on the requester simply by replying to an ambiguous the bac employed shifting rationales therefore lacks merit. nicole contends that the district court failed to give adequate weight to this alleged conflict. with a medical expert only in cases involving a “medical issue.” id. at 850. no disputed medical counsel the phrases “applicable state law,” “laws of the state,” and “state law” appear throughout the [shawn] was deemed and presumed under the law of the locale to be intoxicated.” the language plan. one of the plan’s exclusions, exclusion 12, provides that no benefits will be paid if the turning now to the bac’s cross-appeal, we examine whether the district court erred in nicole next contends that the bac failed to perform a full and fair review of her claim. husband, shawn cultrona, in june 2011. nicole, an employee of a nationwide affiliate, was a the final issue on appeal is whether the district court erred in awarding nicole only $55 a “copy of the latest updated summary, plan description, and the latest annual report, any it used the phrase “law of the locale” in exclusion 12. considering the circumstances surrounding the document request. see kollman, 487 f.3d at 145 sound and nicole offers no compelling reason for us to reach a contrary conclusion. accept our sincere apologies for the error and the confusion it caused and extend counsel. that employee, however, was instructed by a nationwide employee to send only a copy namely, shawn’s intoxication and the resulting application of exclusion 12—stayed the same ins. co. v. banco de seguros del estado, no. 10 c 5039, 2013 wl 3874027, at *6 (n.d. ill. july nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 3 cross-appeals followed. which the plan is . . . operated.” id. if a plan administrator fails to respond to a request for one incorrectly. the policy was amended in january, 2010 effectively changing record and/or supporting nationwide’s decision.” starline forwarded the appeal to nationwide per day, rather than the $110 per day she requested as a penalty for the bac’s delay in providing may consider the resulting potential for a conflict of interest when determining whether the cross-motions for judgment on the administrative record, the district court entered judgment in 26, 2013) (discussing the “law of th[e] locale” in reference to state law); rotec indus., presumed” to be intoxicated as a matter of law. according to nicole, the bac improperly relied documents supporting its decision to deny benefits in this case. see anderson v. flexel, inc., 47 nicole has pointed out several cases in which federal courts have construed the word employee retirement income security act of 1974 (erisa) and a common-law locale in which the injury is sustained, to be driving or operating a motor vehicle while under the the plan’s internal administrative procedures. the claim was based on the death of nicole’s was “[a]sphyxia by extreme and restricted position (positional asphyxia)” and the manner of demand for § 1024(b)(4) documents with the administrator’s own request for greater specificity. “covered person [is] deemed and presumed, under the law of the locale in which the injury is erisa’s implementing regulations and the bac’s charter require such a consultation. as the (holding that there was “no about face in the reason defendants denied” a claim where the basic nor did the district court err in concluding that another ohio statute supported the bac’s it was cold to the touch. the summit county medical examiner’s office performed an autopsy examiner is a disinterested medical expert.”). because nicole’s conflict-of-interest argument is 13-3585 and appellee-cross-appellant in 13-3585. on brief: kelly s. lawrence, mark l. │ │ timely send her a copy of the policy, her arguments on this point are perfunctory and provide nicole’s counsel with a copy of the accidental-death policy until june 12, 2012. cultrona v. nationwide life ins. co., 936 f. supp. 2d 832, 859 (n.d. ohio 2013). the before: gilman, cook, and mckeague, circuit judges. precluded the payment of benefits because “shawn cultrona’s death was caused by . . . [a]cute where the claim was initially denied for failure to provide documentation, but later denied report incorporated a criminal-history search, shawn’s motor-vehicle records, the summit │ rationale for denying the claim was consistent) (internal quotation marks omitted). throughout. see mcclain v. eaton corp. disability plan, 740 f.3d 1059, 1065 (6th cir. 2014) for the plan, later that same month. the total value of the claim was $212,000. after receiving that the plan administrator acted improperly. see id. and, as the district court explained in its of neck and torso while intoxicated.” shawn’s blood-alcohol level at the time of the autopsy was evaluating the quality of [the plan administrator’s] decisionmaking process.” id. a claimant of the locale,” not ohio state law. and the “law of the locale,” nicole contends, must mean the must be upheld so long as it is “the result of a deliberate, principled reasoning process and if it is nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 4 unfounded, and either made in bad faith or with a complete misreading of the policy and that the accidental-death policy was the key document supporting its decision to deny nicole’s moothart v. bell, 21 f.3d 1499, 1506 (10th cir. 1994) (noting that the “circuits are in general occurrence which happens suddenly and violently.” but not every accident is covered under the in the report, however, belies this assertion, stating that the manner of death was “[a]cute ethanol nicole next asserts that the “coroner’s report does not support a legal finding that decision to deny nicole’s appeal. the district court held that shawn was deemed to be court imposed a penalty of $55 per day (for a total of $8,910) against the bac. these timely participant in the plan. among other benefits, the plan provided coverage in the event of an benefits are payable under the plan if a covered person suffers an “injury” as a result of disability action based on an administrative record.” helfman v. ge grp. life assurance co., for review by the bac. prejudice to nicole in calculating the amount of the penalty. this consideration was proper. see │ administrators under § 1132(c) for excessive delay in providing those documents. see fisher death. additionally, since the deceased’s blood level content was in excess of the maximum penalty explained that “the deceased’s blood level content [sic] was in excess of the level at which ohio plan. she next sought statutory penalties as a result of the bac’s failure to timely provide her accidental death. shawn was a covered person under the plan, and nicole was the designated for all of the reasons set forth above, we affirm the judgment of the district court. nationwide for processing. rodio, michael e. smith, frantz ward llp, cleveland, ohio, for appellant/cross- under these circumstances, the district court did not abuse its discretion in concluding document request as including a request for a copy of the accidental-death policy. in making this recommended for full-text publication sustained, to be under the influence of alcohol or intoxicating liquors.” (emphasis in original). for this reason, the cases relied on by nicole for the proposition that the bac employed the medical examiner’s report determined that death occurred when the deceased ┐ pursuant to 29 u.s.c. § 1132(c)(1), the district court imposed an $8,910 penalty against the bac impose a penalty “up to” the statutory limit). here, the district court considered the lack of death was “[a]cute ethanol intoxication . . . accident: prolonged and extreme hypertension the bac argues that the district court erred in construing nicole’s broadly worded (6th cir. 2012). from coverage by exclusion 12 above. impose a penalty against the plan administrator of up to $110 per day. │ medical examiner in this case. see cultrona, 936 f. supp. 2d at 851 n.9 (“[t]he medical denial letter explained that the claim was being denied because “the loss is precluded from “required to engage in quasi-judicial activity when inquiring into the cause of death”). (“each decision depend[s] upon the circumstances of that case and no general rule can be the same to mrs. cultrona. a copy of amendment i is included for your “locale” as referring to cities or counties. nevertheless, the bulk of authority supports the certificate . . . , shall be the legally accepted manner and mode in which such death occurred.” v. metro. life ins. co., 895 f.2d 1073, 1077 (5th cir. 1990) (explaining that § 1132(c) “must be nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 11 interpretations of a disputed term proffered by the plaintiff and the plan administrator were united states court of appeals hand, the bac (on behalf of itself and the other defendants) asks us to affirm the judgment in its │ appeal from the united states district court nationwide life insurance company, counsel, in a november 18, 2011 letter, requested “all documents that you contend prove that file name: 14a0065p.06 │ issue was present in this case because nicole did not introduce any evidence to rebut the of the district court in all respects. as noted above . . . [t]he requirements for coverage under the policy are not met against the bac for its delay in providing nicole with a copy of the accidental-death policy after covered by erisa and as such, mrs. cultrona has the right to appeal the denial. start. nicole argues that the bac failed to determine whether shawn was “deemed and home on june 5, 2011. shawn had gone out drinking the night before, while nicole and the must do more than offer general inferences of a conflict based on self-interest. id. but the only the claim, starline obtained an investigative report from emsi investigative services. that b. the district court correctly concluded that the denial was not arbitrary or although nicole’s proffered interpretation of the phrase “law of the locale” is a rational plaintiff-appellant/cross-appellee, no. 5:12-cv-00444—sara e. lioi, district judge. insufficient to show that the plan administrator acted arbitrarily or capriciously). we are with an independent medical professional before denying her appeal. │ argument nicole makes beyond such inferences is her contention that the bac did not consult one, it is equally rational to conclude that “law of the locale” means state law. see morgan we review the imposition of a penalty under the abuse-of-discretion standard and any favor, but separately contends that the district court erred in the imposition of a penalty against starline responded to counsel’s letter seven days later. in its reply, starline summit toxicology report indicates that the deceased’s blood ethanol level was abused its discretion in imposing a statutory penalty under § 1132(c). presumes intoxication as a matter of law.” nicole contends that this language must refer to ohio her written request for relevant documents. states, 770 f. supp. 54, 56 (d.p.r. 1991) (same); babcock v. maple leaf, inc., 424 f. supp. 428, for the northern district of ohio at akron f.3d 243, 248 (7th cir. 1995) (“courts have suggested . . . that an administrator’s knowledge of on ohio’s drunk-driving statute. nicole points to starline’s initial denial letter, in which it 573 f.3d 383, 392 (6th cir. 2009) (internal quotation marks omitted). because the plan that process is set forth in the original denial letter, a copy of which is enclosed. see kollman v. hewitt assocs., llc, 487 f.3d 139, 145 (3d cir. 2007) (adopting the standard are inapposite. see cultrona, 936 f. supp. 2d at 849 (explaining that erisa claims were twofold. first, nicole sought payment of the death benefits pursuant to the beneficiary upon written request is set forth in 29 u.s.c. § 1024(b)(4). these documents include applies, and (2) the bac’s actions show that it was predisposed to deny her appeal from the of exclusion 12. the reply further explained: nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 5 life insurance company (nationwide), the nationwide death benefit plan (the plan), the twinsburg police department report. starline subsequently forwarded these materials to § 1024(b)(4) must “provide clear notice to the plan administrator of the information they desire.” that the bac knew or should have known that the policy was being requested as one of the ronald lee gilman, circuit judge. nicole cultrona filed suit against nationwide _________________ nicole discovered shawn’s body in the first-floor bathroom of their twinsburg, ohio she notes that each member of the bac is a director-level or higher employee of nationwide. administrative record and/or supporting nationwide’s decision.” the bac, however, did not reference. defendants’ victory, however, was only partial. agreeing with nicole that the bac had argument, the bac urges us to adopt the “clear-notice” standard, a standard that several of our supported by substantial evidence.” id. (internal quotation marks omitted). finally, where the capricious nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 2 because the claimant did not meet the policy’s definition of disabled). nicole’s argument that this argument is unavailing because a file-only review does not compel the conclusion of the statute,” but that “these are factors the district court may consider in deciding to exercise pursuant to sixth circuit i.o.p. 32.1(b) sister circuits have adopted. under this standard, claimants seeking documents pursuant to influence of alcohol or intoxicating liquors.” (emphasis in original). the letter continued: not supported by the record in this case, we find it without merit. c. the district court did not abuse its discretion in awarding nicole a statutory penalty nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 9 of discretion.”); hamilton v. carell, 243 f.3d 992, 997 (6th cir. 2001) (explaining that findings required to resolve a tie in favor of the plan administrator. see id. accordingly, nicole’s as a consequence of this delay. nationwide, in turn, directed starline to deny nicole’s claim in october 2011. the ii. analysis ┘ conclusions contained in the coroner’s report. the district court’s resolution of this issue was nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 7 appellee. daniel w. srsic, lisa m. kathumbi, littler mendelson, p.c., columbus, terminal report, the bargaining agreement, trust agreement, contract, or other instruments under opinion in january 2012, the bac denied nicole’s appeal. the bac explained that exclusion 12 and collecting similar cases from the second, fifth, seventh, and tenth circuits). we see merit laws of twinsburg, ohio, which has no ordinance equivalent to orc § 313.19. she notes that its discretion to award a penalty”). strictly construed” because it is a penalty provision). we further note that a plan administrator is see vargo, 516 n.e.2d at 229 (holding that the “coroner’s report and death certificate . . . create to timely provide her with a copy of the accidental-death policy upon written request. nicole’s on june 05, 2011 and found the deceased dead on the bathroom floor. according v. skf usa, inc., 385 f.3d 989, 992 (6th cir. 2004) (holding that “equally rational” 29 f.3d 1062, 1068 (6th cir. 1994) (“because [erisa] expressly grants a district court intoxicated.” neither the bac nor the district court erred in relying on this report, particularly inc. v. aecon grp., inc., 436 f. supp. 2d 931, 936 (n.d. ill. 2006) (same); coto orbeta v. united i. background the list of documents that a plan administrator must furnish to a participant or .22%. provided notice of amendment no. 1 . . . and all documents comprising the administrative [a]s you noted, this “was a complete misreading of the policy and exclusion 12.” │ argument regarding the alleged insufficiency of the coroner’s report thus has no merit. unconvincing. the district court therefore did not abuse its discretion in awarding nicole only coverage by exclusion 12.” unfortunately, the letter cited an earlier version of exclusion 12 that or should have known which documents were being requested. id. applied only in cases involving the operation of motor vehicles. “29 c.f.r. § 2560.503-1(h)(3) pertains only to group health plans,” not to accidental-death to ensur[e] that the individual participant knows exactly where he stands with respect to the 0.220. “plan administrator both decides a claimant’s eligibility for benefits and pays [those benefits], we this does not show that the bac acted arbitrarily or capriciously in denying nicole’s appeal. see mode in which the death occurred, as . . . incorporated in the coroner’s verdict and in the death acknowledged that the initial denial letter contained an erroneous reference to an earlier version amendment i was inadvertently overlooked when the letter was prepared. please provided as follows: “the covered person being deemed and presumed, under the law of the starline employee to propose sending a “copy of the policy and amendment” to nicole’s _________________ an “accident.” an accident is defined in the policy as “an unintended or unforeseeable event or nationwide benefits administrative with regard to the present case, we discern no abuse of discretion by the district court in a. standard of review $55 per day as a statutory penalty for the bac’s delay. nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 8 nos. 13-3558/3585 cultrona v. nationwide life ins. co. et al. page 10 under the arbitrary-and-capricious standard. id. this means that the decision denying benefits given that nicole failed to offer any contrary evidence regarding the cause of shawn’s death. under a conflict of interest because it is a division of nationwide. pointing to the bac’s charter, a non-binding, rebuttable presumption” concerning the facts regarding a death). nicole’s the exclusion cited in our denial letter dated october 21, 2011, was quoted opinion, the summit county medical examiner’s office functioned as a de facto independent nicole argues that orc § 313.19 is inapplicable because exclusion 12 refers to the “law consult an independent medical professional before denying her appeal. she argues that discretion in imposing penalties for an employer’s failure to disclose, we review only for abuse with a copy of the accidental-death policy. breached its statutory duty to provide her with plan-related documents upon written request, the committee, nationwide death benefit plan, and starline stumbling and walking into chairs prior to driving himself home. the police report states that they responded to the deceased’s home at 1146 hours cultrona v. nationwide life ins. co., 936 f. supp. 2d 832, 847–48 (n.d. ohio 2013); see also _________________ couple’s young child had spent the night at a friend’s house. when nicole found shawn’s body, based on the amended exclusion 12 language, nationwide has determined that we review de novo the “decision of a district court granting judgment in an erisa nicole filed a claim for accidental-death benefits with starline, the claims administrator │ kollman, the key question under the clear-notice standard is whether the plan administrator knew favor of the defendants, but assessed a statutory penalty of $55 per day (for a total of $8,910) finally, nicole contends that the bac acted arbitrarily and capriciously by failing to nicole cultrona, county medical examiner’s office reports (autopsy, investigation, and toxicology), and the shifting rationales are distinguishable. see, e.g., wenner v. sun life assurance co. of can., 482 ins. co., 710 f.3d 651, 664 (6th cir. 2013). instead, a conflict is simply “another factor in d. the district court did not abuse its discretion in awarding nicole less than the


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