Viera v. Life Insurance Co. of North America

642 F.3d 407, 51 Employee Benefits Cas. (BNA) 2097, 2011 U.S. App. LEXIS 11703, 2011 WL 2279175
CourtCourt of Appeals for the Third Circuit
DecidedJune 10, 2011
Docket10-2281
StatusPublished
Cited by128 cases

This text of 642 F.3d 407 (Viera v. Life Insurance Co. of North America) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Viera v. Life Insurance Co. of North America, 642 F.3d 407, 51 Employee Benefits Cas. (BNA) 2097, 2011 U.S. App. LEXIS 11703, 2011 WL 2279175 (3d Cir. 2011).

Opinion

OPINION OF THE COURT

FISHER, Circuit Judge.

This appeal arises out of the 2008 death of Frederick Viera (‘Viera”) in a head-on motorcycle accident. At the time of his death, Viera was covered under an employer-provided accidental death and dismemberment policy (“Policy”), issued by Life Insurance Company of America (“LINA”), and subject to the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1101 et seq. Vi-era’s wife and the executrix of his estate, Hetty Viera (“Plaintiff’), submitted a claim under the Policy following his death. LINA denied Plaintiffs claim, both initially and on appeal. Subsequently, Plaintiff filed suit, but the United States District Court for the Eastern District of Pennsylvania found for LINA on cross-motions for summary judgment. It concluded that the Policy gave LINA discretionary authority to determine eligibility. It therefore reviewed LINA’s decision under a deferential abuse-of-discretion standard and held that LINA was entitled to summary judgment. We conclude that deferential review was not appropriate, given the language of the Policy, and thus remand for further proceedings.

I.

A. Factual History

On October 14, 2008, Viera was seriously injured in a motorcycle accident in Grand Junction, Colorado. He was treated at St. Mary’s Hospital and Medical Center (“St. Mary’s”) for approximately three hours and subsequently died.

On the date of his death, Viera maintained the Policy, an employer-provided accidental death and dismemberment poli *411 cy regulated under ERISA. 1 The Policy was issued and administered by LINA.

Viera had a pre-existing chronic condition known as atrial fibrillation, which was diagnosed prior to LINA’s issuing the Policy. As part of the medical treatment for this condition, Viera received medication called Coumadin (also known as Warfarin). Coumadin is a prescription oral anticoagulant drug prescribed for the prevention and treatment of blood clots.

Following Viera’s motorcycle accident, doctors at St. Mary’s made several findings regarding his treatment and death. For example, the Final Assessment made in the Emergency Report confirmed that Viera was “on Coumadin with therapeutic INR 2 significantly complicating trauma management.” (App. at 160.) The Discharge Summary prepared by Dr. Michael Bradshaw of St. Mary’s described Viera’s death as caused by “multiple injuries in a head-on motorcycle versus car accident with severe pelvic fractures, lower extremity fractures, and a fully coumadinized patient due to atrial fibrillation.” (Id. at 138.)

The Certificate of Death confirmed that the immediate cause of Viera’s death was “multiple injuries,” and it ambiguously noted that “arteriosclerotic cardiovascular disease” was a “condition [ ] contributing to death but not related to [immediate cause].” (Id. at 227.) The autopsy report, prepared by Robert A. Kurtzman, listed the immediate cause of death as “multiple injuries” and listed “other significant conditions” including “atrial fibrillation.” (Id. at 237.)

Plaintiff submitted a claim for benefits under the Policy to LINA on November 3, 2008. LINA denied her claim. Key to this appeal is the language of several Policy provisions:

“Covered Loss”:
A loss that is all of the following:
1. the result, directly and independently of all other causes, of a Covered Accident;
2. one of the Covered Losses specified in the Schedule of Covered Losses;
3. suffered by the Covered Person within the applicable time period specified in the Schedule of Benefits.

(Id. at 78) (emphasis added).

“Covered Accident”:
A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and meets all of the following conditions:
1. occurs while the Covered Person is insured under this Policy;
2. is not contributed to by disease, Sickness, mental or bodily infirmity;
3. is not otherwise excluded under the terms of this Policy.

(Id.)

“Proof of Loss”:
Written or authorized electronic proof of loss satisfactory to Us must be given to Us at Our office, within 90 days of the loss for which claim is made.

(Id. at 85) (emphasis added).

LINA denied Plaintiffs claim by finding that the specific circumstances of Viera’s *412 death did not constitute a covered event under the terms of the Policy. Specifically, LINA maintained that Viera’s accident was excluded by the “Medical Condition Exclusion” of the Policy, which states that:

[Benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from ... [sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food.

(Id. at 83.) LINA concluded that Viera’s Coumadin treatment complicated his medical treatment and constituted a contributing factor to his death. LINA relied on a report by Dr. Mark H. Eaton, a medical doctor it had retained to review the accident reports and hospital records. Dr. Eaton reviewed the hospital records, the autopsy report, and the official Death Certificate in reaching his conclusion. Dr. Eaton reported that:

The cause of Mr. Viera’s death was attributed to the traumatic pelvic fracture which resulted in clinically significant pelvic and retroperitoneal hemorrhage complicated by the fact that the claimant was systematically anti-coagulated.... In my opinion [Viera’s] Coumadin therapy significantly contributed to his death as it is more than likely he would have survived the traumatic pelvic fracture if he had not been fully anti-coagulated at the time of his injury.

(Id. at 124.) Plaintiff administratively appealed the denial of benefits in a written letter to LINA. She chose not to supplement the record with information supporting her claim at that time. LINA affirmed its decision to deny benefits.

B. Procedural History

Plaintiff filed an ERISA action against LINA in the Court of Common Pleas of Philadelphia County, Pennsylvania. LINA removed the action to the United States District Court for the Eastern District of Pennsylvania pursuant to 28 U.S.C.

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642 F.3d 407, 51 Employee Benefits Cas. (BNA) 2097, 2011 U.S. App. LEXIS 11703, 2011 WL 2279175, Counsel Stack Legal Research, https://law.counselstack.com/opinion/viera-v-life-insurance-co-of-north-america-ca3-2011.