Opinion
Case No. 1:01-CV-144TC
May 21, 2003
ORDER
In this Employee Retirement Income Security Act of 1974 ("ERISA") action. Plaintiff Joseph C. Evertsen seeks to recover accidental death benefits under an insurance policy covering his late wife. Emogene N. Evertsen. Defendant Unum Life Insurance Company of America ("Unum") denied Mr. Evertsen's claim for benefits because Unum claims that (I) Ms. Evertsen's death was not caused solely by external, violent, and accidental means and independent of any other causes. and (2) Ms. Evertsen's death was caused by a "disease of the body." Unum did not act arbitrarily and capriciously in determining that Ms. Evertsen's death was not caused solely by an accident. Consequently, the court GRANTS Unum's motion for summary judgment and DENIES Mr. Evertsen's motion for summary judgment.
BACKGROUND
I. The Parties and the Policy
The Evertsens were enrolled in a Voluntary Accident Insurance Plan (the "Plan") through Mr. Evertsen's employment with Herff Jones, Inc. Unum underwrites the Herff Jones Plan. The Plan is an employee welfare benefit plan as that term is defined in 29 U.S.C. § 1002 of ERISA. See 29 U.S.C. § 1002 (2002). The Plan's terms of coverage for accidental death benefits were set out in a document titled "Group Accidental Death Dismemberment Policy" (the "Policy"). (See Policy, attached as Ex. A. ("Def.'s Ex. A") to Def.'s Mem. Supp. Mot. Summ. J. ("Def.'s Supp. Mem.").) The Policy's provisions are discussed below where relevant.
II. Ms. Evertsen's Death
On January 7, 2000, Ms. Evertsen backed her car into a utility pole in a parking lot in Logan, Utah. That evening, Ms. Evertsen went to the emergency room at Logan Regional Hospital complaining of lower back pain and a dull headache.
Dr. Doug Plowman's emergency room note reported that "[t]here has been no head or neck injury." (Emergency Room Note, Def.'s Ex. C.) Ms. Evertsen's neurologic examination was unremarkable, as was an x-ray of' her lumbar spine. The emergency room note reported that among other medications. Ms. Evertsen took Coumadin and Lovenox, which are anticoagulant (blood thinner) medications.
On January 9, 2000, Ms. Evertsen complained to Mr. Evertsen that she had a severe headache. Ms. Evertsen lost consciousness and paramedics took her to Logan Regional Hospital. A CT scan at the hospital revealed a very' large, left subdural hematoma (swelling containing blood in the brain),
Ms. Evertsen was flown by helicopter to McKay-Dee Hospital. Two units of fresh frozen plasma were administered during the flight. Upon arrival at McKay-Dee hospital. Ms. Evertsen was in a coma. She immediately underwent brain surgery.
Ms. Evertsen's condition did not improve. On January 17, 2000, artificial life support was disconnected. Ms. Evertsen died later that day. The attending neurosurgeon, Christopher Penka, M.D., signed the death certificate. He listed as the cause of' death "diencephalic mesencephalic pontomedullary failure," due to "prolonged comatose state," due to "acute massive left subdural hematoma." (Death Certificate, Def.'s Ex. B.) Dr. Penka listed "Chronic Coumadin therapy for thrombocytosis/atrial fibrillation" as a "significant condition contributing to death but not resulting in the underlying cause given in Part I." (Id.)
III. Ms. Evertsen's Prior Medical History
Ms. Evertsen was 62 years old at the time of her death. She had a long and complicated medical history, mostly due to a condition called antiphospholipid syndrome. Steven Salisbury, M.D., Ms. Evertsen's internal medicine physician, stated that antiphospholipid syndrome "is a rather rare condition that . . . affects the blood and clotting system which results in a hypercoaguable state. This predisposes [someone] to both arterial and venous blood clots, or `thrombosis', that can result in either stroke, myocardial infraction, or deep venous thrombosis and pulmonary embolism (blood clots in the legs that can move to the lungs and block arteries)." (Letter from Salisbury to Walsh of 6/30/00, Def.'s Ex. F, at I.) After being formally diagnosed with the syndrome in 1997. Ms. Evertsen was maintained on anticoagulant therapy, including aspirin and Coumadin. This therapy causes the blood to thin, thereby increasing the risk of bleeding complications.
IV. Unum's Evaluation and Denial of the Claim
On January 31, 2000, Herff Jones submitted an accidental death claim to Unum on behalf of Mr. Evertsen. Unum's Medical Consultant, Kristen G. Sweeney, M.D. reviewed Ms. Evertsen's medical records on April 10, 2000. Dr. Sweeney concluded that Ms. Evertsen's death was not caused solely by external, violent, and accidental means and independent of any other causes. Specifically, Dr. Sweeney reported to Unum that
Neither an immediate nor a delayed acute subdural hematoma is the expected result of a motor vehicle collision with a utility pole at low speed, in a healthy young adult restrained by a seatbelt. "That is particularly unexpected in the absence of even a minor head trauma.
. . . The chronic Coumadin therapy for Antiphospholipid Syndrome was a significant contributing condition because it made Mrs. Evertsen more susceptible to bleeding from minimal trauma. Therefore, the death was not caused solely by external, violent and accidental means and independent of any other cause.
(Medial Report, Def.'s Ex. K. at 4.)
Unum denied the claim on April 20, 2000. The denial letter stated in part,
Our Medical Consultant has reviewed the medical records received from the offices of Steven Salisbury, M.D. and V. Duane Bohman, M.D., of Logan, Utah; the Logan Regional Hospital, Logan, Utah. the McKay-Dee Hospital, Ogden, Utah, and the death certificate. Based on this review, our Medical Consultant has determined that Mrs. Evertsen's Antiphospholipid Syndrome and her chronic anticoagulation therapy with Coumadin and aspirin was a significant contributing factor causing her acute subdural hematoma. Therefore, the loss of life did not result from a bodily injury that is solely caused by external, violent and accidental means and independent of any other cause, but by disease of the body. Therefore, we must advise you that no benefits are payable on this claim.
(Letter from Mills to Evertsen of 4/20/00 ("Mills Letter"), Def.'s Ex. J. at I.)
On July 24, 2000, Mr. Evertsen requested an appeal of Unum's decision denying the claim. Mr. Evertsen submitted additional materials with his request for appeal, including a letter from Dr. Salisbury. In his letter, Dr. Salisbury disputed Dr. Sweeney's conclusions. Specifically, he explained that (1) "a direct cranial trauma is not required for subdural hematoma to occur" and (2) a delay of forty-eight hours in the onset of symptoms of a subdural hematoma is common. (Letter from Salisbury to Walsh of 6/30/00 ("Salisbury Letter"), Def.'s Ex. F, at 4 (internal quotation omitted).) He concluded that Ms. Evertsen "died of a subdural hematoma that was temporarily associated with an accident in a parking lot. Mrs. Evertsen's condition that required chronic Coumadin anticoagulation may have predisposed her to a subdural hematoma but certainly did not cause this." (Id.)
Unum asked Dr. Sweeney to review Dr. Salisbury's opinion. She again concluded that
the chronic Coumadin therapy for Antiphospholipid Syndrome was a significant contributing condition because it made Ms. Evertsen more susceptible to bleeding after sustaining minimal trauma (presumably the "shaking" or whiplash injury).
It is the Coumadin therapy for the disease, not the disease itself, which contributed to the bleeding.
(Medical Report of 10/19/00, Def.'s Ex. M. at 2.) Dr. Sweeney noted medical reports that (1) cited "subdural hematoma as a well-recognized and potentially fatal complication of anticoagulant therapy (warfarin or Coumadin, in particular)" and (2) discussed the increased risk of "developing an intracranial hematoma in partients on chronic warfarin (Coumadin therapy)." (Id.) Based on Dr. Sweeney's second review, Unum upheld its denial on January 19, 2001,
V. Procedural Background
On or around October 4, 2001, Mr. Evertsen filed a Complaint in the First Judicial District Court for the State of Utah. Unum filed a notice of removal in this court on November 6, 2001, asserting both diversity jurisdiction under 28 U.S.C. § 1332 and federal question jurisdiction under 28 U.S.C. § 1331. Specifically. the notice of removal explained that Mr. Evertsen's action arose under 29 U.S.C. § 1132 (a)(1)(B). "in that it seeks benefits under an Employee Benefit Plan under [ERISA])." (Notice of Removal, at 2.)
Mr. Evertsen's Complaint, which does not mention 29 U.S.C. § 1132 (a)(1)(B), states a claim for breach of contract. (See Complaint, attached as Ex. A to Notice of Removal, at 3.) "Although not styled as such, this case arises under 29 U.S.C. § 1132, which provides the exclusive remedy for the failure to obtain benefits from an ERISA plan."Winchester v. Prudential Life Ins. Co., 975 F.2d 1479, 1483 (10th Cir. 1992).
Unum filed a motion for summary judgment on September 30, 2002. Unum contends that it did not act arbitrarily or capriciously in denying benefits because (1) Ms. Evertsen's death was not caused solely by her accident, independent of any other cause, and (2) the Policy excludes losses "caused by. contributed to by. or resulting from . . . disease of the body [or] bodily or mental infirmity." (See Policy, Def.'s Ex. A, at 4, 7.) Mr. Evertsen, refuting Unum's arguments. filed a motion for summary judgment on November 25, 2002.
Mr. Evertsen filed this motion after the September 30, 2002 dispositive motions cut-off date. Nevertheless, the court considers Mr. Evertsen's reply memorandum.
ANALYSIS
I. Legal StandardA. The Standard for Summary Judgment
The standard that applies generally for motions for Federal Rule of Civil Procedure 56 applies for motions for summary judgment in 29 U.S.C. § 1132 cases. See, e.g., Woolsey v. Marion Labs., Inc., 934 F.2d 1452, 1456 (10th Cir. 1991); Vander Pas v. Unum Life Ins. Co., 7 F. Supp.2d 1011, 1016 (E.D. Wis. 1998); Utah Alcoholism Found. v. Battelle Pacific Northwest Labs.-Non-Bargaining Unit Employees' Comprehensive Med. Benefits Plan, 204 F. Supp.2d 1295, 1299 (D. Utah 2002). A court therefore should grant a movant's motion for summary judgment "if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law.'" Fed.R.Civ.P. 56(c); see Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986); Adler v. Wal-Mart Stores, Inc., 144 F.3d 664, 670 (10th Cir. 1998). A genuine issue of material facts exists if "there is sufficient evidence favoring the non-moving party for a jury to return a verdict for that party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249 (1986); see also Adler, 144 F.3d at 670.
In weighing a summary judgment motion, a court construes evidence in the light most favorable to the non-moving party and draws all justifiable inference in the non-movant's favor. See Anderson, 477 U.S. at 255; Aramburu v. Boeinig Co., 112 F.3d 1398, 1402 (10th Cir. 1997). The Tenth Circuit has stated that "`[i]n reviewing decisions of plan administrators under the arbitrary and capricious standard, the reviewing court may consider only the evidence that the administrators themselves considered' on or before the final decision denying benefits." Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999) (quoting Chambers v. Family Health Plan Corp., 100 F.3d 818, 823, 824 (10th Cir. 1996)).
B. Standard of Review for Recovery of Benefits Claim
Mr. Evertsen seeks to recover benefits due to him pursuant to 29 U.S.C. § 1132 (a)(1)(B). As a threshold issue, the Plan in the present case gives Unum "discretionary authority to determine the Insured's eligibility for benefits and to interpret the terms and provisions of [the] policy." (Policy, attached as Ex. A. to Def.'s Supp. Mem., at 1.) Consequently, the arbitrary and capricious standard applies in this case. See Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) (holding that "a denial of benefits challenged under [29 U.S.C.] § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan"); Sandovol v. Aetna Life and Cas. Ins. Co., 967 F.2d 377, 379-80 (10th Cir. 1992) (stating that where a plan gives an administrator discretionary authority, courts should apply the arbitrary and capricious standard).
29 U.S.C. § 1132(a) provides:
A civil action may be brought . . . by a participant or beneficiary . . . to recover benefits due to him under the terms of the plan to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan. . . .
As stated above, although Mr. Evertsen's Complaint did not mention 29 U.S.C. § 1132 (a)(1)(B), that statute "provides the exclusive remedy for the failure to obtain benefits from an ERISA plan."Winchester, 975 F.2d at 1483.
In the context of a summary judgment motion in an ERISA case involving a denial of benefits, "the ultimate question . . . is whether a reasonable factfinder could conclude, based on the evidence before [him or her], that the plan administrator's decision to deny' the plaintiff. benefits was, in fact, arbitrary and capricious." Vander Pas, 7 F. Supp.2d at 1016. "An administrator's action is arbitrary and capricious if it is based on a `lack of substantial evidence, mistake of law, bad faith, [or] conflict of interest.'" Counts v. Kissack water and Oil Serv., Inc., 986 F.2d 1322. 1324 (10th Cir. 1993) (quoting Winchester v. Prudential Life Ins., 975 F.2d 1479, 1483 (10th Cir. 1992)). Because Mr. Evertsen does not allege that Unum made a mistake of law, acted in bad faith. or had a conflict of interest, the court analyzes his claims under the substantial evidence standard. See id.
Under the substantial evidence standard, the court does not "substitute [its] judgment for the judgment of the [Administrators] unless the actions of the [Administrators] are not grounded on any reasonable basis." Woolsey, 934 F.2d at 1460 (quoting Oster v. Barco of California Employees' Retirement Plan, 869 F.2d 1215, 1218 (9th Cir. 1989) (additional quotations omitted)): see also Kimber, 196 F.3d at 1098. "[T]he Administrator['s] decision need not be the only logical one nor even the best one. It need only be sufficiently supported by facts within [his] knowledge to counter a claim that it was arbitrary and capricious."Kimber, 196 F.3d at 1098 (quoting Woolsey, 934 F.2d at 1460).
II. Was Ms. Evertsen's Death Caused by an "Injury" as Defined by the Policy?
Unum claims that it properly denied benefits to Mr. Evertsen's because Ms. Evertsen's death was caused in part by her Coumadin therapy and therefore was not caused by an "injury" as defined by the Policy. The Policy provided that Unum would pay benefits only for a "loss" caused by an "injury." (See Policy, Def.'s Ex. A. at 5.) The Policy defined "injury" as "a bodily injury that is solely caused by external, violent and accidental means and is independent of any other cause." (Id. at 4 (emphasis added).) Given Unum's evidence showing that Ms. Evertsen's Coumadin therapy helped bring about her death, it is clear that Unum's decision that Ms. Evertsen's death was not caused by an "injury" as defined by the Policy was not arbitrary and capricious.
The Tenth Circuit has indicated that a Policy provision such as Unum's justifies a denial of benefits where any cause other than an accident partially causes an injury. See Winchester v. Prudential Life Insurance Co., 975 F.2d 1479, 1488 (10th Cir. 1992). In Winchester, the plan participant died of heart failure following a training exercise. Id. at 1482. The accidental death policy in question conditioned coverage on "the employee having sustained an accidental bodily injury" and "the injury, directly and independently of all other causes, having resulted in the loss." Id. at 1482-83 (alterations omitted). The court upheld the district court's grant of summary judgment in the insurance company's favor in part because the the plaintiff did not "prove that the death occurred independently of any other cause, including a preexisting bodily infirmity." Id. at 1487-88. Specifically, the plaintiff's evidence, which included an expert's testimony that "people that have heart attacks generally have heart disease," "indicated that it was more likely than not that [the deceased] had preexisting heart disease." Id. at 1488. Additionally, no evidence in the record "refuted [the] likelihood set forth by [the Plaintiff's] own witness of a preexisting infirmity." Id.
The fact that the "other cause" that precluded recovery of accidental death benefits in Winchester was heart disease, a "preexisting infirmity." distinguishes that case from Mr. Evertsen's. See id. at 1488-89. Nevertheless, the Policy in the present case did not confine "other cause" to preexisting infirmities. (See Policy, Def.'s Ex. A. at 4.) Further, the Policy did not specifically exclude claims resulting from drug therapy from the category of "other causes." (See id. at 7.) Even if an ambiguity existed us to whether Coumadin therapy may constitute an "other cause." the court "must defer to the plan administrator's interpretation of policy terms under the arbitrary and capricious standard." Winchester, 975 F.2d at 1488; see also Kimber, 196 F.3d at 1100.
In the present case, both parties rely on language in Ms. Evertsen's death certificate to show whether Ms. Evertsen's Coumadin therapy helped bring about her death. Part I of Ms. Evertsen's death certificate listed an "immediate cause," defined as a "[f]inal disease or condition resulting death," and two subsequent "conditions . . . leading to immediate cause" of her death. (Death Certificate, Def.'s Ex. B.) The death certificate also lists chronic Coumadin therapy as a "significant condition contributing to death but not resulting in the underlying cause given in Part I." (Id.) Mr. Evertsen cites the exclusion of Coumadin therapy from the list of "immediate" or "underlying" causes as evidence that Coumadin therapy did not cause Mr. Evertsen's death. Unum cites the listing of Coumadin therapy as a significant contributing condition as evidence that Ms. Evertsen's death was not caused solely and in dependently by the car accident.
Mr. Evertsen also relies on a letter by Dr. Salisbury. Dr. Salisbury specifically stated that "Mrs. Evertsen's condition that required chronic Coumadin anticoagulation may have predisposed to her [sic] a subdural hematoma but certainly did not cause this." (Salisbury Letter, Def.'s Ex. F, at 4.)
Dr. Salisbury also testified to the same effect in an affidavit. "`[I]n reviewing decisions of plan administrators under the arbitrary and capricious standard, the reviewing court may consider only the evidence that the administrators themselves considered' on or before the final decision denying benefits." Kimber, 196 F.3d at 1098 (quoting Chambers v. Family Health Plan Corp., 100 F.3d 818, 823, 824 (10th Cir. 1996)). Dr. Salisbury's affidavit, dated November 18, 2002, post-dates Unum's final decision to deny benefits. Accordingly, the court has not considered either Dr. Salisbury's November 18, 2002 affidavit or any other evidence that was not before Unum on January 19, 2001.
Unum, in turn, points to Dr. Sweeney's medical report. which states that "[t]he chronic Coumadin therapy for Antiphospholipid Syndrome was a significant contributing condition because it made Mrs. Evertsen more susceptible to bleeding from minimal trauma." (Medical Report, Def.'s Ex. K, at 4.) Mr. Evertsen argues that Dr. Sweeney's conclusions do not constitute substantial evidence because Dr. Sweeney stated in her April 10, 200 medical report that "[t]here was no head trauma and [Ms. Evertsen] had no neurologic findings when evaluated five hours [after the accident]." (Id.) Dr. Sweeney's second medical report, however, which responded to Dr. Salisbury's conclusions, specifically noted that Ms. Evertsen had complained of a headache on January 7, 2000. (See Medical Referral, Def.'s Ex. M, at 1.) Further, Dr. Sweeney's conclusion contemplated a possible head trauma. She explained that
[w]hether Mrs. Evertsen sustained an undocumented minor impact to her head or whether she sustained a whiplash injury (luring the reportedly low-speed rear impact of a motor "vehicle with a utility pole while restrained, an acute subdural hematoma is not an expected outcome in a healthy 62 year-old adult.
(See id. at 2.)
The evidence on which Unum relied — namely the death certificate and Dr. Sweeney's medical reports — was sufficient to support Unum's determination to deny benefits to Ms. Evertsen. Because substantial evidence supported Unum's decision that Ms. Evertsen's death was not caused solely by her car accident, the decision was not arbitrary and capricious. See Kimber, 196 F.3d at 1098 (stating that "the Administrator['s] decision need not be the only logical one nor even the best one. It need only be sufficiently supported by facts within [his] knowledge to counter a claim that it was arbitrary and capricious" (quoting Woolsey, 934 F.2d 1452, 1460 (10th Cir. 1991)). Accordingly, the court DENIES Mr. Evertsen's motion for summary judgment on this issue and GRANTS Unum's motion for summary judgment
III. Did Unum Properly Deny Benefits to Ms. Evertsen Under the "Disease of the Body" Exclusion?
In denying Mr. Evertsen's accidental death claim, Unum also relied on the Policy's "disease of the body" exclusion. That provision excludes claims for losses "caused by, contributed to by, or resulting from . . . disease of the body, bodily or mental infirmity, or any bacterial infection other than bacterial infection due directly to an accidental cut or wound." (Policy, Def.'s Ex. A, at 7); See Vander Pas v. Unum Life Insurance Co., 7 F. Supp.2d 1011, 1016-17 (E.D. Wis. 1998) (discussing Coumadin therapy' in the context of a policy's pre-existing condition exception). Because substantial evidence supported Unum's conclusion that Ms. Evertsen's death was not caused by an "injury" as defined by the Policy, the court need not determine whether substantial evidence supported Unum "s contention that Coumadin therapy constitutes a "disease of the body."
ORDER
For the foregoing reasons, Unum's motion for summary judgment is GRANTED and Mr. Evertsen's motion for summary judgment is DENIED.