Viera v. Life Insurance Co. of North America

871 F. Supp. 2d 379, 2012 U.S. Dist. LEXIS 67667, 2012 WL 1694459
CourtDistrict Court, E.D. Pennsylvania
DecidedMay 15, 2012
DocketCivil Action No. 09-3574
StatusPublished
Cited by2 cases

This text of 871 F. Supp. 2d 379 (Viera v. Life Insurance Co. of North America) is published on Counsel Stack Legal Research, covering District Court, E.D. Pennsylvania 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, 871 F. Supp. 2d 379, 2012 U.S. Dist. LEXIS 67667, 2012 WL 1694459 (E.D. Pa. 2012).

Opinion

MEMORANDUM

EDUARDO C. ROBRENO, District Judge.

I. INTRODUCTION

Plaintiff Hetty Viera (“Plaintiff’) brings this action pursuant to the Employee Retirement Income and Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)(B) (2006), seeking payment of benefits under an accidental death and dismemberment policy arising from the death of her husband, Frederick Viera (“Viera”). Defendant Life Insurance Company of North America (“Defendant”) denied benefits under the accidental death and dismemberment policy. The case is on remand to this Court from the United States Court of Appeals for the Third Circuit.

Currently before the Court is Plaintiffs request for additional discovery in order for the Court to conduct a de novo review of Defendant’s denial of benefits. For the reasons that follow, the Court will deny Plaintiffs request.

II. BACKGROUND

On October 14, 2008, Viera was involved in a motorcycle accident in Grand Junction, Colorado. Viera suffered serious injuries as a result of the accident. He was treated at St. Mary’s Hospital and Medical Center (“St. Mary’s”) for approximately three hours and was subsequently pronounced dead.

On the date of his death, Viera maintained two insurance policies, which were purchased on his behalf by his employer, Hornbeck Offshore Operators, L.L.C. These insurance policies consisted of an employer-provided life insurance policy, and an employer-provided accidental death and dismemberment policy (the “AD & D Policy” or the “Policy”). The claims administrator for each of these policies is [382]*382Defendant. Only the AD & D Policy is the subject of the instant litigation.

Viera had a pre-existing chronic condition known as atrial fibrillation before Defendant issued the AD & D Policy. See Def.’s Br. in Supp. of Mot. for Summ. J. Ex. C, at 123-25, 210, ECF No. 29. As part of the medical treatment for his atrial fibrillation, Viera received a medication called Coumadin (also known as Warfarin).1 See id. at 135-38.

Plaintiff is Viera’s wife and the executrix of his estate. On November 3, 2008, Plaintiff submitted a claim for benefits under the AD & D Policy to Defendant, but Defendant denied this claim.2 Defendant’s position was that Viera’s death was not a covered event under the express terms of the AD & D Policy. One relevant provision of the AD & D Policy, defines a “Covered Loss” as:

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 27 (emphasis in original). Another relevant provision of the AD & D Policy defines a “Covered Accident” as:

A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or a 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. The AD & D Policy also contains a provision that specifically excludes the following from a claim for benefits:

[A]ny Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from ... [sjickness, 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 32. Defendant contends that this exclusion (the “Medical Condition Exclusion”) dictates that Viera’s loss was excluded from coverage under the AD & D Policy. More specifically, Defendant denied Plaintiffs benefit claim on the ground that Viera’s Coumadin treatment complicated his medical treatment and constituted a contributing factor to his death after his accident.

After Defendant denied Plaintiff benefits at the administrative level, Plaintiff filed suit on July 10, 2009. The parties submitted cross-motions for summary judgment. On April 6, 2010, upon consideration of the parties’ cross-motions for summary judgment, the Court granted Defendant’s motion for summary judgment and denied Plaintiffs motion for summary judgment. In doing so, the Court evaluated Defendant’s denial of benefits under the deferential abuse of discretion standard [383]*383because the policy language in the plan stated that proof of loss must be “satisfactory to [Defendant].” Viera v. Life Ins. Co. of N. Am., No. 09-3574, 2010 WL 1407312, at *4 (E.D.Pa. Apr. 6, 2010). Applying the abuse of discretion standard, the Court concluded that the evidence supported Defendant’s decision to deny benefits because there was reasonable medical evidence that the death was caused, at least in part, by Viera’s use the blood thinner Coumadin. Id. at *7-8. The Court reached this conclusion despite the fact that Plaintiffs expert, Dr. Aaron Gindea, opined that Viera’s death was not directly or indirectly caused by Coumadin. See id. at *8 (stating courts in ERISA context “have recognized that the decision of a plan administrator will not be deemed an abuse of discretion merely because it chooses among competing medical opinions”).

In addition, the Court denied Plaintiffs motion for summary judgment based upon an interpretation of the Policy. Specifically, the Court held that the Medical Condition Exclusion in the Policy excluded from a Covered Injury or Loss such injuries or losses that were directly or indirectly, in whole or in part, caused by medical or surgical treatment of any of the following: sickness, disease, bodily or mental infirmity, or bacterial or viral infection. See id. at *11 (rejecting Plaintiffs argument that phrase “medical or surgical treatment thereof’ applied only to “bacterial or viral infection[s]” and not entire list of ailments).

On appeal, the Third Circuit held that the Court erroneously reviewed Defendant’s decision under the abuse of discretion standard and remanded the case for the Court to review de novo whether Defendant properly denied benefits. See Viera v. Life Ins. Co. of N. Am., 642 F.3d 407, 418 (3d Cir.2011). The Third Circuit also, however, affirmed the Court’s interpretation of the Medical Condition Exclusion. Id. at 419-20. After the Third Circuit remanded to this Court, the Court held a status and scheduling conference. At that conference, the Court ordered the parties to submit briefing on how the Court is to conduct this de novo review. Both parties submitted briefs to this Court, and the matter is now ripe for disposition.

III. DISCUSSION

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
871 F. Supp. 2d 379, 2012 U.S. Dist. LEXIS 67667, 2012 WL 1694459, Counsel Stack Legal Research, https://law.counselstack.com/opinion/viera-v-life-insurance-co-of-north-america-paed-2012.