Opinion
Civil Action 2:09-cv-1066.
December 14, 2010
Opinion and Order
Plaintiff Dain C. Akin, the Administrator of the Estate of Anita Snow, brings this action under ERISA alleging that defendant Unimerica Insurance Company arbitrarily and capriciously denied the Estate's claim for an accidental death benefit. This matter is before the Court on the motions of the parties for judgment on the administrative record (docs. 20 and 21).
Factual overview. On December 18, 2008, Anita Snow, a 60-year-old woman suffering from end stage renal disease, arrived at the Grant Medical Center emergency room. Her daughter-in-law brought Ms. Snow there because she was suffering from vomiting and diarrhea and "was unsteady on her feet". She was concerned that Ms. Snow's "left-sided weakness had gotten worse." At the ER, Ms. Snow was "a very poor historian." She was dehydrated, and the physician suspected sepsis. On examination, her legs were weak. She did not seem to have ataxia. The diagnostic impressions were: (1) questionable transient ischemic attack; (2) nausea, vomiting and diarrhea; (3) history of prior cerebrovascular accident; and (4) dementia. The ER staff admitted her to the hospital. There her treators were concerned about her altered mental status and needed to determine whether she had sepsis or had suffered a neurological event. Because of a decrease in her cognition and her state of dehydration, Ms. Snow was administered intravenous fluids and started on broad spectrum antibiotics. Blood cultures indicated that she was suffering bacterial infection. (UNI00101-102 and UNI00101-104-105.)
The next morning, there was concern Ms. Snow was developing sepsis. A blood culture was positive for a staph infection, and her urine was positive for e. coli. Her dialysis catheter was a possible source for the bacteria, so it was removed. Her neurological status was improved and she could tolerate oral intake. Her vital signs were stable, and she was alert, oriented, and responding appropriately to questions. Her neurological and motor exams appeared to be normal, except for a slight weakness on the upper left side. (UNI00102.)
On December 23, while walking unassisted from the bathroom, she fell and struck her head. Although the fall was not witnessed, Ms. Snow reported the head injury. A December 19 CT scan of the head had been negative, and a December 23 CT scan of the head after she reported the fall showed no acute intracranial abnormality. A neurological examination was normal. (UNI00101-102.) But on December 24, after a transesophageal echocardiogram, she was noted to have deterioration in her mental status and was very difficult to arouse. The symptoms were initially attributed to oversedation. When there was no improvement after several doses of an anti-opioid, a neurological exam was conducted. It showed unequal pupils that did not react to light. Ms. Snow was transferred to the ICU, and given a repeat CT scan. This confirmed a large new subdural hematoma with a midline shift to the left. A neurosurgeon was consulted, who concluded that Ms. Snow was not a candidate for surgery. (UNI00102.) Her family agreed to allow the withdrawal of life sustaining measures, and Ms. Snow died on December 26, 2008. (UNI00101-103.)
The coroner concluded: "Death is considered to be related to subdural hematoma due to fall. Sepsis and end stage renal disease are considered to be contributing factors." (UNI00108.) The autopsy revealed "a large recent subdural hematoma on the right side" of the brain, "rather marked atherosclerotic change" to the cerebral arteries, evidence of an old cerebral infarct, and "[n]o apparent recent or old contusions . . . on the surface of the brain." (UNI00110.) There were marked atherosclerotic changes in the coronary arteries, mitral valve replacement, a pacemaker implant, and multiple areas of old infarct of the myocardium. (UNI00111.)
Accidental death policy terms. Ms. Snow, as a participant in an employee benefit plan, had a group life and accidental death insurance policy issued by the Unimerica Insurance Company. This policy provided, as part of its accidental death and dismemberment benefit provision, that:
If the Covered Person suffers a loss described below, We will pay the amount of insurance that applies. The Covered Person, or the Covered Person's beneficiary, must give Us proof that:
1. Injury occurred while the insurance was in force under this section;
2. loss occurred within 365 days after the injury; and
3. loss was due to injury independent of all other causes.
(UNI00018.) The policy defined "injury" as "[a] bodily injury resulting directly from an accident and independently of all other causes." (UNI00009.) The policy further provided that a benefit will not be paid "for a loss caused directly or indirectly by . . . disease, bodily or mental infirmity, or medical or surgical treatment of these. . . ." (UNI00019.)
Processing the claim. Plaintiff David C. Akin, the administrator of Ms. Snow's estate, submitted a request for payment of the accidental death benefit. On May 21, 2009, Defendant Unimerica, through its plan administrator, denied payment of the benefits:
Although "Subdural Hematoma" is listed as the primary cause of death, since Ms. Snow was admitted to the hospital for "complaint of nausea and vomiting and slight weakness on the left side," to a degree that she was admitted to the hospital, it has not shown that the bodily injury resulted directly from an accident and independently of all other causes. Specifically the autopsy report indicates that the "Sepsis and end stage renal disease are considered to be contributing factors" and lists in Final Anatomic Diagnoses:
"3. Sepsis, clinical.
4. End stage renal disease with dialysis, clinical.
5. Coronary atherosclerosis, marked, with multiple old myocardial infarcts.
6. Cardiomegaly.
7. Status post replacement of mitral valve, remote.
8. Thrombosis of superior vena cava.
9. Status post removal of the uterus, ovaries and tubes, remote.
10. Status post appendectomy.
11. Status post multiple hospital treatments.
12. Possible old cerebral infarct."
(UNI00052.) Plaintiff appealed that determination, and on August 31, 2009, Dr. Francis A. Bellino, M.D., Defendant's vice president and chief medical officer, reviewed the claim record. After summarizing the medical record, Dr. Bellino gave the following analysis:
On review of the medical data in the file, Ms. Snow was seriously ill at that time of her fall. Although the injury sustained was ruled the cause of death, it was not independent of all other causes. Immediately following the injury, the CT scan of the head was unremarkable as was her evaluation clinically. Her use of Plavix (presumbably for her artificial mitral valve) would contribute bleeding following the injury. The neurosurgery consultation opined that she was not a surgical candidate which would be attributable to her serverely impaired health due to her multiple medical conditions.
Dr. An [the pathologist] clearly opined that the sepsis and the end stage renal disease contributed to Ms. Snow's death. My review of the medical data agrees with Dr. An's opinion.
. . .
Although the subdural hematoma was ruled the cause of death, it was not independent of all other causes as explained above.
(UNI00045-46.) On September 10, 2009, Unimerica again denied the claim, stating in relevant part:
As you know, on May 21, 2009 you were informed that the Group Accidental Death claim for Anita Snow was not payable. Specifically, it was explained that because her death was not solely due to an accidental injury, the policy requirements were not met for claim approval.
. . .
Therefor, although the cause of death was determined to be the head injury Ms. Snow suffered due to her fall, other factors contributed to her death. Dr. An writes as such: ". . . Death is considered to be related to subdural heatoma due to fall. Sepsis and end stage renal disease are considered to be contributing factors . . ." As a result, both Dr. An and the Medical Consultant [Dr. Bellino] agree Ms. Snow's death was not due to an injury and independent of all other causes, since her medical conditions are considered contributing factors. As the policy states:
Limitations: We will not pay a benefit for a loss caused directly or indirectly by:
1. disease, bodily or mental infirmity, or medical or surgical Treatment of these, . . ."
"Treatment: consultation, advice, tests, attendance or observation, supplies or equipment, including the prescription or use of prescription drugs or medicines."
Accordingly, we have made the decision to uphold the original adverse determination, and no benefits are payable.
(UNI00047-48.)
Plaintiff has now brought suit against Defendant pursuant to 29 U.S.C. § 1132, part of the Employee Retirement Income Security Act ("ERISA").
Neither party disputes either the factual record in this case, or the standard of review to be applied to it. The sole dispute is whether Defendant, as a plan administrator, with discretionary authority to determine eligibility for benefits and interpret the terms of the plan, acted in an "arbitrary and capricious" manner in making its decision to deny benefits. Under this standard, the Court must uphold the administrator's decision if its "interpretation of the Plan's provisions is `reasonable'." Morrison v. Marsh McLennan Cos., 439 F.3d 295, 300 (6th Cir. 2006), citing Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 111 (1989). Moreover, the Court "must accept a plan administrator's rational interpretation of a plan even in the face of an equally rational intepretation offered by the participants." Morgan v. SKF USA, Inc., 385 F.3d 989, 992 (6th Cir. 2004). Nevertheless, in interpreting a plan, the administrator must adhere to the plain meaning of its language as it would be construed by an ordinary person. Id., citing Shelby County Health Care Corp. v. S. Council of Indus. Workers Health and Welfare Trust Fund, 203 F.3d 926, 934 (6th Cir. 2000). The "arbitrary and capricious" standard is not a "rubber stamp" of the plan administrator's decision. Glenn v. MetLife Ins. Co., 461 F.3d 660, 666 (6th Cir. 2006). Instead, it requires a court to review "the quality and quantity of the . . . evidence and the opinions on both sides of the issues." McDonald v. W.S. Life Ins. Co., 347 F.3d 161, 172 (6th Cir. 2003).
Contractual interpretation. The parties have briefed the question of whether the policy provides that benefits are payable if the injury is independent of all other causes, or if the death is independent of all other causes. The policy provides that benefits will be paid if "loss was due to injury independent of all other causes." Plaintiff argues that a plain reading of this phrase indicates that "independent of all other causes" modifies "injury". He refers to the "Last Antecedent" rule of construction, which holds that a limiting clause should ordinarily be read as modifying only the noun or phrase immediately preceding it. Plaintiff maintains that Ms. Snow's death was due to hematoma — a bodily injury resulting directly from a fall, that was independent of all other causes. Therefore, Plaintiff argues, benefits are payable under the literal terms of the contract.
Defendant maintains in its motion for judgment on the pleadings, that the policy required "death to be the result of an accident and independent of all other causes". (Doc. 20 at 10, emphasis in original.) It cited to Sangster v. Metropolitan Life Ins. Co., 54 F.Supp.2d. 708 (E.D. Mich. 1999), in which the court upheld a denial of benefits where a woman who had been in a car accident then died from her heart disease instead of from her injuries received, on grounds that benefits were properly denied "where interdependent accidental and non-accidental causes of death are present." Id. at 712. Denial was likewise proper here, Defendant argued, because "[t]here is substantial evidence in the record that Ms. Snow's death was contributed to by medical conditions independent of the injuries she sustained as a result of the fall." (Doc. 20 at 9, emphasis added.)
The policy at issue in Sangster, explicitly provided that death must be from injuries "caused solely by an accident." Id.
In its reply brief, however, Defendant then apparently took the new position that "[t]he Policy at issue . . . clearly requires the death itself, as well as the injury, to be the result of an accident and independent of all other causes." (Doc. 24 at 7, emphasis added.) This seems to put forward a contractual interpretation that the clause in question modified both "loss" and "injury". It continued to maintain that Ms. Snow's death had contributing causes, such as end stage renal disease. However, it also briefly returned to its original theory from the May 21, 2009 initial denial of claim. Noting that the medical record showed that, on intake, Ms. Snow had weakness in her extremities and was reported not steady on her feet, and that she had suffered from numerous illnesses and debilitating conditions, Defendant argued:
It is certainly reasonable to conclude that a person with all these serious underlying medical conditions did not fall solely as a result of an accident and that her underlying medical conditions likely contributed to and may have been the primary cause of her fall. Indeed, there is repeated references in the record to Ms. Snow suffering from weakness in her extremities. (UNI00102, UNI00105.) For these reasons, it was reasonable for Unimerica to conclude that Ms. Snow's fall, and the resulting subdural hematoma, was not the result of an accident and independent of all other causes.
(Doc. 24 at 6, emphasis added.)
Construction of policy language. The accidental death provisions of the policy require the covered person's beneficiary to provide proof that "loss was due to injury independent of all other causes." (UNI00009.) Further, the "Limitations" term of the accidental death policy provides that Unimerica "will not pay a benefit for a loss caused directly or indirectly by . . . disease, bodily or mental infirmities, or medical or surgical Treatment of these. . . ." (UNI00019.) Thus, the policy covers a "loss" that was "due to injury". As the language of the limitation makes clear, the "loss," here Ms. Snow's death, must be "independent of all other causes." (UNI00009.) In addition, the "injury" causing the loss is defined as "A bodily injury resulting directly from an accident and independently of all other causes." (UNI00009.) Consequently, and somewhat confusingly, both the "loss" and the "injury" must be "independent of all other causes".
"Loss of life" is the first covered loss listed under accidental death coverage. (UNI00018.)
The initial May 21, 2009 denial of the claim can be read to rely on both the finding that the injury was not independent of all other causes and that the loss (death) was due to accident but not independent of all other causes. It both asserts that since Ms. Snow was admitted to the hospital with complaints of nausea, vomiting and slight weakness on the left side, "it has not shown that the bodily injury resulted directly from an accident and independently of all other causes" and that "Although `Subdural Hematoma' is listed as the primary cause of death, . . . the autopsy report indicates that the `Sepsis and end stage renal disease are considered to be contributing factors'. . . ." to the primary cause of death. (UNI00052.) The September 10, 2009 final denial of the claim is based solely on the finding that the loss, Ms. Snow's death, was not independent of all other causes. (UNI00047-48.) Then in its briefs in this Court, Defendant argues both positions. Because Defendant denied the claim for both reasons and argued both reasons in its briefs, the Court will consider both below.
Was the injury independent of all other causes? Accidents or mishaps which occur during the course of medical treatment can certainly fall outside the scope of accidental death policies such as the one at issue here. In Swisher-Sherman v. Provident Life Accident Ins. Co., 37 F.3d 1500 (6th Cir. 1994), the court listed numerous cases in which a person had died, during the course of medical treatment, due to some anticipated, accidental, mistaken, or negligent event. However, it found, not every accident is the result of a medical condition simply because it takes place in the hospital. "The cause of death would be only adventitiously connected to the medical treatment; it is the sort of accident that might equally occur in one's home." Swisher-Sherman, 37 F.3d at *2, quoting Senkier v. Hartford Life Accident Ins. Co., 948 F.2d 1050, 1054 (7th Cir. 1991.)
Here, there is little evidence beyond supposition that Ms. Snow's fall was caused in whole or in part by illness. Defendant points out that her daughter-in-law reported at the time of admission that Ms. Snow had been "unsteady on her feet" and had suffered "weakness" in her extremities. However, the hospital record thereafter reflects only that, the next morning, Ms. Snow was "alert", "oriented", "responding appropriately to questions", and that "her neurologic and motor exams appeared to be normal with no focal deficits." The record specifically notes that "[t]here may have been a slight weakness noted on the left side in her upper extremity however she was doing very well", and makes no comment about her lower extremities. Aside from this, Defendant only points to the decedent's other conditions such as endocarditis, urinary tract infection, and sepsis, without offering any rationale for why these might cause a person to fall. Plaintiff points out that the hospital staff apparently did not feel that Ms. Snow was in danger of hurting herself; she was permitted to walk alone and unassisted to the bathroom, rather than being in a hospital bed with side-rails or an alarm. The record reflects that Ms. Snow was alone when the accident occurred, and that she was, for some period of time after the accident, lucid enough to give an account of what had happened, which does not indicate a patient so incapacitated or disoriented by illness that unassisted movement in her condition was likely to cause a fall. Defendant asserts that "[i]t is certainly reasonable to conclude that a person with all of these serious underlying medical conditions did not fall solely as a result of an accident and that her underlying medical conditions likely contributed to and may have been the primary cause of her fall." (Doc. 24 at 6.) But this conclusion is not reasonable without any evidence that this supposition is true, beyond a general impression that sick people are more likely to fall.
Defendant states, for instance, that Ms. Snow:
underwent a transthorasic echocardiograph that confirmed she had endocarditis (heart valve infection) and a "vegetation" on her heart valve, which is a colony of bacteria that grow on the heart valve that prevent the heart valve from operating properly. This is a serious medical condition. It was after the transthorasic echocardiograph, confirming she had endocarditis, that Ms. Snow apparently fell in the bathroom and hit her head.
(Doc. 24 at 6.) Left unexplained, however, is why endocarditis (or a recent diagnosis of it) would cause a person to fall down and strike her head.
The (somewhat limited) hospital records forming part of the administrative record in this case recounted the incident in this manner:
During her recovery, however she did suffer a fall while ambulating unassisted from the bathroom and it was also unwitnessed; however, she did report she sustained a head injury and during her initial evaluation there were no concerns however, a CT of the head was performed and was negative. Her neurological exam was normal and her care continued.
(UNI00102.)
In Kovach v. Zurich American Ins. Co., supra, the court was faced with a person who, while somewhat intoxicated and operating a motorcycle, ran a stop sign and collided with another vehicle. His accidental death and dismemberment insurer denied coverage for the insured's subsequent loss of his leg, on grounds that, as the insured's injuries were caused by his drunk driving, they were not "accidental". The court found this denial of coverage unreasonable, arbitrary, and capricious. It compared the Kovach facts with an earlier case, Lennon v. Metropolitan Life Ins. Co., 504 F.3d 617 (6th Cir. 2007), with similar facts. In Lennon, however, the insured had a blood-alcohol level nearly to the point of semi-consciousness, and had suffered an accident after driving at high speed the wrong way down a one-way street. The Kovach court found that, while in Lennon death was so reasonably likely that the incident could not be characterized as an "accident", a person injured in circumstances which had merely tended to make injury somewhat more likely had suffered what a typical policyholder would consider an "accident".
In the case at bar, a general supposition that a very ill woman would be more likely to fall is not enough without some actual evidence of impairment to make Ms. Snow's fall an injury simply associated with illness rather than an accident independent of other cause. The plan administrator could not, without some basis, rationally make the assumption that people in Ms. Snow's condition were simply prone to falls.
There can be no doubt, as Defendant states, that at the time of her death Ms. Snow was a "very sick person". (Doc. 24 at 6.) However, her fall, and the blow to her head, might equally have happened at home, or she might have suffered a head injury from an automobile accident on the way to the hospital. The record is bare of evidence that would support the conclusion that her diseases somehow caused the fall. To the extent that the plan administrator's decision to deny benefits was based on the conjecture that her medical conditions must have contributed to the fall, it is arbitrary and cannot be sustained.
Was the loss independent of all other causes? The autopsy report and Dr. Bellino both reached the conclusion that although Ms. Snow's death was caused by the blow to her head, it was contributed to by sepsis and end stage renal disease. Further, Dr. Bellino noted that Ms. Snow's medication likely contributed to the bleeding following her injury and that she was not a surgical candidate because of her severely impaired health. Since the medical record contains reliable evidence that other medical conditions contributed to Ms. Snow's death due to the subdural hemotoma, Unimerica's denial of the accidental death benefit claim was not arbitration and capricious.
Conclusions.
For the foregoing reasons, the Court finds that the decision of Defendant as plan administrator to deny benefits was not arbitrary and capricious. Accordingly, Plaintiff's motion for judgment on the administrative record (Doc. 21) is DENIED, and Defendant's motion (Doc. 20) is GRANTED. The Clerk of Court is DIRECTED to enter JUDGMENT for Defendant.