Prather v. Sun Life Financial Distributors, Inc.

174 F. Supp. 3d 1022, 2016 WL 1242093, 2016 U.S. Dist. LEXIS 40663
CourtDistrict Court, C.D. Illinois
DecidedMarch 29, 2016
DocketNO. 14-3273
StatusPublished

This text of 174 F. Supp. 3d 1022 (Prather v. Sun Life Financial Distributors, Inc.) is published on Counsel Stack Legal Research, covering District Court, C.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Prather v. Sun Life Financial Distributors, Inc., 174 F. Supp. 3d 1022, 2016 WL 1242093, 2016 U.S. Dist. LEXIS 40663 (C.D. Ill. 2016).

Opinion

OPINION

RICHARD MILLS, United States District Judge:

This is an action for declaratory judgment, pursuant to 28 U.S.C. §§ 2201 and 2202, and other relief.

Both parties have moved for Summary Judgment.

I. INTRODUCTION

This case is brought pursuant to ERISA § 502(e)(1) & (2), as well as 29 U.S.C. § 1132. Plaintiff Lee Ann Prather is an individual domiciled in Sangamon County, [1024]*1024Illinois. Defendant Sun Life and Health Insurance Company (U.S.) is a corporation organized and existing under the laws of the State of Connecticut, and doing significant business in Illinois.

Plaintiff Lee Ann Prather asserts she is entitled to accidental death and dismemberment benefits on her husband Jeremy Prather’s life. The accidental death benefits were pursuant to Mr. Prather’s employer welfare benefit plan (“Plan’’) funded by Group Life Insurance Policy No. 54-0000 (“Policy”) issued by Defendant Sun Life Financial Distributors, Inc.

The Policy was issued to the Springfield Urban League, Inc., her husband’s employer. The Plaintiff alleges that Jeremy Prather sustained an injury during a pickup basketball game which eventually led to his death. As a result, the Plaintiff asserts she is entitled to recover accidental death benefits under the policy, in addition to reasonable attorney’s fees in connection with the prosecution of the claim.

The Defendant alleges Jeremy Prather’s death was attributable to natural causes and not the result of an accident.

II. FACTUAL BACKGROUND

(A)

Jeremy Prather was hired on December 8, 2011 by the Springfield Urban League, Inc., as a Coordinator. Incident to his employment, Mr. Prather participated in the Plan with basic life insurance and accidental 'death benefits funded by the Policy issued by Sun Life, which also served as the Plan’s claims review fiduciary. The Plan is subject to ERISA.

At all relevant times, Mr. Prather was an employee of the Springfield Urban League and was an insured eligible for benefits under the Policy. The group- insurance coverage issued to Springfield Urban League, Inc. insures basic life and accidental death and dismemberment benefits afforded under the Springfield Urban League, Inc.’s Plan. Mr. Prather’s insurance coverage under the Group Policy includes an accidental death benefits clause, stating:

Accidental Death and Dismemberment Benefit
_We will pay a benefit based , on the amount shown in the Insurance Schedule if, while you are insured under the policy, you sustain bodily injuries:. •
1. That result directly from an accident and independently of all other causes;
2. That, within 365 days of the date of the accident, result in one of the losses listed below; and
3. That aré not excluded in the “Restrictions” section below.
Restrictions
_We will not pay a benefit for any loss that is caused, either directly or . indirectly, or contributed to, by:
1. Physical or mental infirmity or disease.
[...]
7. Medical or surgical treatment,

Mr. Prather carried accidental death and dismemberment benefits, in an amount 200 percent of his basic annual earnings, amounting to $93,814.79.

The Policy contains a discretionary clause which provides, in pertinent part, as follows:

Claims Fiduciary
Sun Life and Health Company (U.S.) as Claims Fiduciary, shall have the sole and exclusive discretion and authority to carry out all actions involving claims procedures explained in the Policy., The Claims Fiduciary shall have the sole and [1025]*1025exclusive discretion and power to grant and/or deny any and all claims for benefits, and construe any and all issues relating to eligibility for benefits. All findings, decisions, and/or determinations of any type made by the Claims Fiduciary shall not be disturbed unless the Claims Fiduciary has acted in an arbitrary and/or capricious manner. Subject to the requirements of law, the Claims Fiduciary shall be the sole judgment of the standard of proof required in any claims for benefits and/or in any question of eligibility for benefits.

On or about July 16, 2013, Mr. Prather sustained a ruptured left Achilles tendon while playing basketball. The Plaintiff alleges Mr. Prather further developed deep vein thrombosis and a pulmonary embolism as a direct result of the accident-related injury. The Defendant asserts Mr. Prather developed deep vein thrombosis and pulmonary embolism subsequent to surgical repair of his ruptured Achilles tendon.

Following Mr. Prather’s basketball-related injury, Rishi Sharma, M.D., discussed deep vein thrombosis and pulmonary embolism with him. On July 16, 2013, Mr. Prather was provided with a CAM walker with a heel lift as well as with crutches. Mr. Prather received a prescription for Vicodin. Dr. Sharma discussed immobilization as well as weight bearing as tolerated and he recommended further consultation and evaluation with Orthopedic Surgery.

On July 21, 2013, Mr. Prather reported by telephone call to the office of Jeffrey Schopp, M.D., that he experienced lower left extremity swelling starting one or two days after rupturing his Achilles tendon.1 Mr. Prather denied redness, streaking, or discoloration, fever or chills,- shortness of breath or chest- pain and indicated he was ambulating with a boot and crutches. He further stated that elevation seemed to decrease the swelling slightly and “there is an area on the outer aspect of his left calf that is more sensitive than the rest of his calf.” Mr. Prather, also stated he was concerned about a blood clot. He was advised to keep his leg elevated above the level of his heart and that he would be evaluated the following day prior to his surgery.

Mr. Prather was evaluated by Dr. Schopp prior to surgery. The surgery to repair Mr. Prather’s ruptured Achilles tendon went forward on July 22, 2013, with no operative complications. The procedural notes provide that Dr. Schopp discussed anesthetic complication, infection, neuro-vascular injury, ' re-rupture, deep vein thrombosis, pulmonary embolism and the usual postoperative course. Mr. Prather and his family stated that they understood the procedure, had an opportunity to ask questions and gave consent.

On August 2, 2013, Mr. Prather presented for staple removal and was told to follow up in four weeks or sooner if any problems occurred. On or about August 6, 2013, Mr. Prather passed away. Mr. Prather’s death resulted minutes after a pulmonary embolism and three weeks after he ruptured his Achilles tendon. In describing the injury, the Certificate of Death provides that while Mr. Prather was playing basketball, another player stepped on.his ankle, causing the tendon to rupture.

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174 F. Supp. 3d 1022, 2016 WL 1242093, 2016 U.S. Dist. LEXIS 40663, Counsel Stack Legal Research, https://law.counselstack.com/opinion/prather-v-sun-life-financial-distributors-inc-ilcd-2016.