Barnes v. American International Life Assurance Co.

681 F. Supp. 2d 513, 2010 U.S. Dist. LEXIS 9503
CourtDistrict Court, S.D. New York
DecidedFebruary 4, 2010
DocketNo. 08 Civ. 06222 (DC)
StatusPublished
Cited by1 cases

This text of 681 F. Supp. 2d 513 (Barnes v. American International Life Assurance Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Barnes v. American International Life Assurance Co., 681 F. Supp. 2d 513, 2010 U.S. Dist. LEXIS 9503 (S.D.N.Y. 2010).

Opinion

OPINION

CHIN, District Judge.

On February 8, 2007, thirty-one year old Trudy Barnes (“Ms. Barnes”) had elective orthopedic surgery to correct an abnormal curvature of her spine. During the surgery, a catheter was improperly inserted into her chest, puncturing a vein. She went into cardiac arrest, and died two days later.

Ms. Barnes was insured under a group accidental death and dismemberment insurance policy (the “Policy”) issued by American International Group through its member company, defendant American International Life Assurance Company of New York (together, “AIG”), to L-3 Communications Corporation (“L-3”). Ms. Barnes’s husband, plaintiff Clint Barnes (“Barnes”), an employee of L-3, had obtained coverage under the Policy for her. He submitted a claim under the Policy for her death.

AIG denied the claim on the basis that the Policy was “an accident only policy and does not cover sickness or disease.” Although it was clear that Ms. Barnes had died from medical malpractice, AIG took the position that her death was not accidental and therefore not covered by the Policy.

Barnes brought this case under the Employee Retirement Income Security Act of 1974 (“ERISA”), to challenge the denial of benefits. Before the Court are the parties’ cross-motions for summary judgment. As explained more fully below, I conclude as a matter of law that Ms. Barnes’s death was the result of an “accident.” Her death was not caused by scoliosis or a back problem or any sickness or disease; to the contrary, she died because a catheter was improperly placed into her chest, rupturing a vein and causing internal bleeding and a profusion of fluids into her chest cavity. This was not supposed to happen. Rather, this was an unintentional, unexpected, unusual, and unforeseen event — n accident. AIG’s determination to the contrary must be set aside as arbitrary and capricious. Accordingly, Barnes’s motion is granted and AIG’s motion is denied. I [515]*515conclude that Barnes is entitled to benefits under the Policy for the accidental death of his wife.

STATEMENT OF THE CASE A. The Facts

Except as otherwise indicated, the facts are not in dispute.

1. The Parties

At all relevant times, Barnes resided in Texas and was employed by L-3 in Texas. (AIG 081, 103;1 see Compl. ¶¶ 1, 3). L-3 has its principal place of business in New York. (Compl. ¶ 4; Answ. ¶ 4). Defendant is a life insurance company with its principal place of business in New York. (Compl. ¶ 5; Answ. ¶ 5).

2. The Policy

L-3 provided its employees and their families with various life and accident insurance plans. (AIG 051). These plans were summarized in a “Summary Plan Description” (the “SPD”) provided to its employees. (AIG 048-082). The SPD notes that it describes “the most important features” of the different life and accidental insurance plans, but explains that the “actual provisions” of the insurance plans were set forth in the respective insurance policies between L-3 and the applicable insurers. (AIG 051).

Barnes had the option to select from different types and levels of coverage. (Pl. 56.1 Statement ¶ 3; Def. 56.1 Response ¶ 3). He also had the option to choose coverage for his dependent spouse, Ms. Barnes. (Pl. 56.1 Statement ¶ 4; Def. 56.1 Response ¶ 4). Barnes elected to obtain coverage for voluntary accidental death and dismemberment insurance, which required him to- pay additional premiums. (Pl. 56.1 Statement ¶¶ 6, 7; Def. 56.1 Response ¶¶ 6, 7). Barnes also obtained voluntary accidental death and dismemberment (“AD & D”) insurance for his wife, with coverage of $148,800. (Pl. 56.1 Statement ¶ 8; Def. 56.1 Response ¶ 8). The Policy was placed with L-3 by a New York City broker and was negotiated and delivered to L-3 in New York. (Pl. 56.1 Statement ¶ 2; Def. 56.1 Response ¶ 2). The Policy provides death benefits as follows:

Accidental Death Benefit. If Injury to the Insured Person results in death within 365 days of the date of the accident that caused the Injury, [AIG] will pay 100% of the Principal Sum.

(AIG 649).

The Policy defines “Injury” as:

bodily injury caused by an accident occurring while this Policy is in force as to the person whose injury is the basis of claim and resulting directly and independently of all other causes in a covered loss.

(AIG 647).

On the cover page, in bold print, the Policy states:

THIS IS AN ACCIDENT ONLY POLICY. IT DOES NOT COVER SICKNESS OR DISEASE.

(AIG 645).

The SPD contains a section on voluntary AD & D insurance coverage (“Voluntary [516]*516AD & D”). (AIG 065-070). It explains that Voluntary AD & D provides “worldwide protection that applies to accidents on or off the job, at home or away from home.” (AIG 065). It explains that benefits will be paid to the beneficiary for death or severe injury, in addition to benefits provided by any other coverage. (Id.). The SPD does not explicitly state, as does the Policy, that sickness and disease are not covered. (AIG 065-070).

Neither the Policy nor the SPD defines “accident.” (AIG 065-070, 647). Both the SPD and the Policy exclude certain losses. The SPD contains a section on “What’s Not Covered,” which specifies that Voluntary AD & D benefits will not be paid for losses resulting from, e.g., suicide, travel on an aircraft owned by L-3, war, full-time active duty in any armed forces (except the National Guard or organized reserve corps duty), being under the influence of drugs or intoxicants (unless taken under the advice of a doctor), and the insured person’s commission of a felony. (AIG 070). Similar exclusions are included in the Policy. (AIG 651). None of these exclusions is implicated in this case. No exclusion is expressly provided for losses resulting from medical treatment or surgery. (AIG 070, 651).

In contrast, the SPD also included a description of a basic AD & D (“Basic AD & D”) plan (AIG 058-059), which specifically excludes injuries resulting from:

medical or surgical treatment, except when the loss is caused by an infection that results directly from the injury, surgery needed because of the injury, or medical malpractice, and the injury is not otherwise excluded under the [Basic AD & D] Plan.

(AIG 059). This language apparently provides that losses resulting from medical or surgical treatment are excluded except when they are caused by medical malpractice.

The SPD also provides:

L-3 ..., as the Plan Administrator, is responsible for administration of the Plan.... The Plan Administrator has the full and complete discretionary authority and responsibility to administer the Plan and may delegate any or all of its authority and responsibility to any individuals or entities by action of its Board of Directors.
The Plan Administrator has delegated to the insurance company the full and complete discretionary authority and responsibility to decide all questions of eligibility for benefits under the Plan. The insurance company’s decisions are final and binding on all persons to the full extent permitted by law.

(AIG 074).

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Related

Barnes v. AMERICAN INTERN. LIFE ASSUR. CO.
681 F. Supp. 2d 513 (S.D. New York, 2010)

Cite This Page — Counsel Stack

Bluebook (online)
681 F. Supp. 2d 513, 2010 U.S. Dist. LEXIS 9503, Counsel Stack Legal Research, https://law.counselstack.com/opinion/barnes-v-american-international-life-assurance-co-nysd-2010.