Mers v. Marriott International Group Accidental Death & Dismemberment Plan

144 F.3d 1014, 22 Employee Benefits Cas. (BNA) 1172, 1998 U.S. App. LEXIS 9399
CourtCourt of Appeals for the Seventh Circuit
DecidedMay 8, 1998
DocketNo. 97-1039
StatusPublished
Cited by11 cases

This text of 144 F.3d 1014 (Mers v. Marriott International Group Accidental Death & Dismemberment Plan) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mers v. Marriott International Group Accidental Death & Dismemberment Plan, 144 F.3d 1014, 22 Employee Benefits Cas. (BNA) 1172, 1998 U.S. App. LEXIS 9399 (7th Cir. 1998).

Opinion

KANNE, Circuit Judge.

Mers appeals the district court’s affirmance of Marriott International Group Accidental Death and Dismemberment Plan’s denial of her claim for benefits. She asserts that two ERISA policies cover her husband’s death. Because the denial was based on a reasonable interpretation of the terms of both policies, we affirm the decision of the district court.

I. History

A.

Dale Mers worked for Marriott International, Inc. (“Marriott”) as a Director of National Sales. On January 4, 1994, as part of his job, he attended a five-day conference sponsored by the Professional Convention Management Association. The kick-off for the conference was a volunteer project with Habitat for Humanity rehabilitating a home. Dale Mers was feeling well, but his participation in this project required an unusual amount of physical exertion for him. He used a sledge hammer and a crow-bar to tear down a plaster wall. While engaged in this activity, he complained of chest pains and collapsed.

Although he was rushed to a hospital, Dale Mers died early in the morning of January 6, 1994. At the time of his death, he was forty-four years old, had non-insulin diabetes, high cholesterol, and was approximately thirty to forty pounds overweight. However, he had never been treated for coronary or vascular problems nor been determined to have any problems with hypertension.

No autopsy was performed on Dale Mers because his family had his body cremated one day after his death. The death certificate listed the cause of death as cardiac arrest due to cerebral hemorrhage resulting from a brain stem infarction. In layman’s terms, he had a heart attack because a blood vessel in his brain burst.

B.

The Marriott International Group Accidental Death and Dismemberment Plan (“Plan”) is a welfare benefit plan that Marriott provides for its employees. It is governed by ERISA. See 29 U.S.C. •§ 1001 et seq. American International Group (“AIG”), a holding company that operates insurance companies through subsidiaries, is insurer of the Plan. A subsidiary of AIG issued policies insuring the Plan’s benefits.

[1018]*1018Marriott employees may choose from two types of accidental death and dismemberment coverages under the Plan. The first is a Business Travel Accident policy (“BTA”) that Marriott provides automatically to every salaried employee. Dale Mers was eligible for $100,000 in benefits. The second is a 24-Hour Optional policy (“24-Hour”) that Marriott offers to all salaried employees as additional coverage if the employee elects to enroll and pays premiums commensurate with the coverage amount selected. Dale Mers enrolled in the 24-Hour policy for $100,000 in benefits. Pamela Mers (“Mers”) was her husband’s designated beneficiary. ,

A summary plan document (“SPD”) encapsulates the scope of coverage and exclusions for these policies. The BTA policy provides insurance protection if the insured should die or lose limbs, eyesight, speech, or hearing in an accident while traveling on Marriott business. The 24-Hour policy pays benefits if the insured suffers an accidental loss of life, limbs, eyesight, speech, or .hearing at any time regardless of whether the person is engaged in Marriott business. Both policies exclude coverage for a loss caused by or resulting from disease of any kind.

Both policies also have the same definition of an injury. The policies define “injury” as “bodily injury caused by an accident ... and resulting directly and independently of all other causes.” The BTA policy has this definition only in its policy terms and not in the SPD; the 24-Hour policy has this definition in both locations.

C.

Shortly after Dale Mers’ death, Marriott provided Mers with a copy of the SPD and a profile of benefits as of January 7, 1994. This profile stated that her husband had $100,000 in accidental death coverage. Unaware that her husband had enrolled in the 24-Hour policy, Mers assumed that this $100,000 coverage was under the BTA policy in which her husband was automatically enrolled.

In submitting Mers’ claim to the Plan, however, Marriott erroneously included only a copy of Dale Mers’ enrollment form for the 24-Hour policy. Marriott did not notify the Plan of Dale Mers’ enrollment in the BTA policy and did not file a formal claim with the Plan for BTA benefits. Thus, the Plan considered only the terms of the 24-Hour policy in evaluating Mers’ claim for benefits. The Plan was unaware that Mers had a potential claim for benefits under the BTA policy.

After Mers submitted a proof of claim form, Marriott forwarded it to American International Company (“AIC”), a subsidiary of AIG, to whom AIG had delegated its duties under the Plan. On August 3, 1994, AIC denied Mers’ claim for benefits. Among other reasons, the letter cited the definition of injury found in the policies and the disease exception in concluding that the 24-Hour policy did not cover Dale Mers’ death. Under the terms of the 24-Hour policy, AIC concluded that an accident did not cause his death.

AIC based its determination on its investigation of the circumstances surrounding Dale Mers’ death, its review of his medical records, and its receipt of the medical opinions of Drs. Daniel Hier and Jack Harnes. Dr. Hier concluded that the exertion that this job placed on Dale Mers, who was not used to performing physical labor, precipitated a sudden rise in blood pressure producing an intracerebral hemorrhage. Although Dr. Hier was unable to conclude whether an aneurysm or arteriosclerosis caused the localized weakening in the blood vessel’s wall, Dr. Hier was able to conclude that Mers’ participation in the Habitat project was not the sole cause of death. Dr. Harnes, AIC’s medical consultant, also opined that the death was not independent of other causes. He concluded that arteriosclerosis resulting from Dale Mers’ diabetes played a role in causing the blood vessel to rupture.

Mers appealed the Plan’s denial. In support of her appeal, Mers submitted the medical opinion of Dr. Allan Aven. Dr. Aven’s report discussed Dale Mers’ activity just pri- or to his collapse and opined that the unusual and extreme physical exertion which Dale Mers experienced working on the Habitat for Humanity project precipitated his cerebral hemorrhage. Even though he argued that exertion was the primary cause of death, Dr. Aven conceded that cholesterol plaque or congenital dysplasia may have previously weakened a blood vessel sufficiently to cause [1019]*1019it to rupture. Thus, Dr. Aven agreed with his colleagues that the acute hemorrhage was at least partially the result of a ruptured cerebral aneurysm or a blood vessel weakened by arteriosclerosis. On December 8, 1994, AIC’s appeals committee affirmed the denial of benefits.

D.

Mers filed a complaint on December 22, 1995 asserting that Marriott wrongfully denied her claim for benefits in violation of ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). When the parties filed cross-motions for summary judgment, they realized that Mers could have asserted two claims, one under each policy. The court allowed Mers to amend her complaint. Both parties agreed that Mers never submitted a claim under the BTA policy for administrative review. The Plan offered to waive any timeliness defense, but Mers refused to proceed administratively, arguing that.it would be futile.

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144 F.3d 1014, 22 Employee Benefits Cas. (BNA) 1172, 1998 U.S. App. LEXIS 9399, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mers-v-marriott-international-group-accidental-death-dismemberment-plan-ca7-1998.