Arruda v. Zurich Am. Ins. Co.

366 F. Supp. 3d 175
CourtDistrict Court, District of Columbia
DecidedFebruary 6, 2019
DocketCIVIL ACTION NO. 17-10105-DPW
StatusPublished
Cited by1 cases

This text of 366 F. Supp. 3d 175 (Arruda v. Zurich Am. Ins. Co.) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Arruda v. Zurich Am. Ins. Co., 366 F. Supp. 3d 175 (D.D.C. 2019).

Opinion

DOUGLAS P. WOODLOCK, UNITED STATES DISTRICT JUDGE

Denise Arruda brings this action against Zurich American Insurance Company *177("Zurich") seeking accidental death benefits pursuant to an employee welfare benefits plan stemming from the death of her husband, Joseph Arruda, in a car accident. Zurich has denied benefits. The parties have separately filed motions for judgment on the administrative record. The parties do not contest the language or meaning of the contract terms, but instead contest the sufficiency of the record evidence to support Zurich's decision. Finding that Zurich's decision is not supported by substantial evidence, I will grant Mrs. Arruda's motion and deny that of Zurich.

I. BACKGROUND

A. Factual Background

1. Mr. Arruda's General Health

Mr. Arruda, age 57, worked as a salesperson for NSTAR in May of 2014. [Administrative Record ("R.") at 3.] He had been suffering from hypertension, hyperaldosteronism, and hypertrophic cardiomyopathy. Mr. Arruda was obese, did not exercise, and did not follow-up with physicians as instructed. [Id. at 333, 335-36.] He also failed to follow his prescription medication regimen. [Id. ]

In January 2014, Mr. Arruda passed out at home and was admitted to the hospital the following day. [Id. at 151.] As a result of that medical episode, he had a ardioverter/defibrillator pacing device surgically implanted in the left side of his chest in January 2014. [Id. at 334.] Mr. Arruda's last medical examination by his cardiologist, Christopher Abadi, M.D., on February 25, 2014, included notes that Mr. Arruda had "done well from a cardiac standpoint since" having the defibrillator implanted and that his "blood pressure was fine." [Id. at 195.]

2. The Policy

Mr. Arruda was insured under Basic Accident Policy No. GTU 4380194 (the "Policy") issued by Zurich. [Id. at 473.] The Policy provides, in relevant part that: "If an Insured suffers a loss of life as a result of a Covered Injury, We will pay the applicable Principal Sum ." [Id. at 96.] It defines a covered injury as "an Injury directly caused by accidental means which is independent of all other causes, results from a Covered Accident , occurs while the Covered Person is insured under this Policy, and results in a Covered Loss ." [Id. at 92.] A covered accident is defined as "an Accident that results in a Covered Loss ." [Id. ] An accident is "a sudden, unexpected, specific, and abrupt event that occurs by chance at an identifiable time and place during the Policy term." [Id. ] Finally, a covered loss is "a loss which meets the requisites of one or more benefits or additional benefits, results from a Covered Injury , and for which benefits are payable under this Policy." [Id. ] The Policy also contains two relevant exclusions: Exclusion 4, which provides that a "loss will not be a Covered Loss if it is caused by, contributed to, or results from ... illness or disease, regardless of how contracted ..." and Exclusion 8, which provides that a loss will not be a covered loss if it is caused by, contributed to, or results from "being under the influence of any prescription drug, narcotic, or hallucinogen." [Id. at 102.]

3. The Car Accident

On the morning of May 22, 2014, Mr. Arruda was driving to the University of Massachusetts-Amherst to attend a work event. [Id. at 1.] At about 9:39 a.m., Mr. Arruda's car crossed the highway median into oncoming traffic and struck another car. [Id. at 147, 471.] The collision caused Mr. Arruda's car to hit a curb, flip over multiple times, and land upright. [Id. at *178143.] CPR was performed on Mr. Arruda. [Id. at 147.] He was pronounced dead on the scene by the Hadley Fire Department. [Id. ] The autopsy report listed Mr. Arruda's cause of death as hypertensive heart disease. [Id. at 834.] A postmortem toxicology report found that Mr. Arruda had marijuana in his system at the time of the crash. [Id. at 842.]

4. The Attempt to Collect

On or about August 19, 2014, Mrs. Arruda filed for accidental death benefits, as beneficiary of the Policy. [Id. at 52.] Zurich then retained the services of an investigator, CS Claims Group, Inc. ("CS Claims"), to investigate the loss. [Id. at 109.] CS Claims investigated over a period of eight months, providing Zurich with 17 reports regarding its progress in collecting medical records, witness statements, and medical examiner reports. [Id. at 125, 128, 132, 135, 189, 269, 331, 399, 400-402, 801, 802, 804, 831-33, 852.]

In a letter dated December 8, 2015, Zurich issued a denial of benefits based on two grounds. [Id. at 473.] First, Zurich concluded that Mr. Arruda's death was not the result of an accidental bodily injury independent of all other causes. [Id. at 475.] Second, and independently, Zurich concluded that the Policy exclusion for loss caused by, contributed to, or resulting from illness or disease, was applicable. [Id. ] Essentially, Zurich concluded that Mr. Arruda's cause of death was hypertensive heart disease such that Mr. Arruda's death was not independent of an underlying medical condition. [Id. at 474.]

On January 29, 2016, Mrs. Arruda filed an appeal of denial with Zurich. [Id. at 477.] In this appeal, Mrs. Arruda submitted an Arrhythmia Logbook report from Boston Scientific, the manufacturer of Mr. Arruda's implantable cardioverter defibrillator ; the hearing transcript from Mr. Arruda's July 1, 2015 workers' compensation hearing; and the workers' compensation lump sum settlement agreement. [Id. at 477.] Mrs. Arruda supplemented her appeal on August 24, 2016 with an expert report from Elizabeth A. Laposta, M.D. [Id. at 1407-1424.]

The appeals committee included four individuals who reviewed the matter de novo. [Id. at 1786.] In assessing Mrs. Arruda's claim, the appeals committee retained a medical opinion from forensic pathologist Mark Taff, M.D. [Id. at 1526.] Zurich submitted a letter to Mrs. Arruda dated February 7, 2017, documenting Dr. Taff's opinion as to Mr. Arruda's cause of death. [Id. at 1584.] In sum, Dr. Taff concluded that Mr. Arruda died as a result of accidental bodily injuries that were contributed to by multiple pre-existing illnesses or diseases, which caused him to lose control of his car and crash. [Id. at 1599-1600.] Within the February 7 letter, Zurich notified Mrs. Arruda that it might raise Exclusion 8 (contribution of drug use) of the Policy with regard to her claim. [Id. at 1584.] Zurich explained that before it issued its final decision, it would give Mrs. Arruda an additional 30 days to review the material and provide any input regarding the Exclusion 8 language. [Id. ] On April 17, 2017, Mrs. Arruda submitted Dr. Laposata's response to Dr. Taff's report for Zurich's review, which included a direct response to Zurich's application of Exclusion 8. [Id. at 1697-1700.]

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366 F. Supp. 3d 175, Counsel Stack Legal Research, https://law.counselstack.com/opinion/arruda-v-zurich-am-ins-co-dcd-2019.