Opinion
Case No. 1:99-CV-127
May 22, 2000
MEMORANDUM OPINION ON THE MERITS IN LIEU OF TRIAL
Plaintiff's decedent, Rosa Close, was an employee of the Planning Research Corporation. As such, she elected to obtain accidental death benefit coverage subject to the terms and conditions set forth in the PRC Employee Accidental Death and Dismemberment Benefits Plan ("Plan"), an employee welfare plan governed by the Employee Retirement Income and Security Act of 1974 ("`ERISA"), 29 U.S.C. § 1001 et seq.
After undergoing elective Roux-en-Y surgery in an attempt to control her severe obesity, Mrs. Close died from resultant complications on November 1, 1997. Thereafter, her husband Michael Close submitted a claim to defendant for accidental death benefits under the Plan. Defendant undertook an investigation of the claim and gave a final denial after appeal on September 4, 1998. On January 28, 1999, plaintiff Michael Close brought suit in state court claiming accidental death benefits. As plaintiff's claim is properly characterized as a claim against the Plan pursuant to 29 U.S.C. § 1132(a)(1)(B), defendant timely removed the suit to this Court on account of the federal question presented under ERISA.
The parties have stipulated that no material facts are in dispute, and have submitted the case to the Court on briefs in lieu of trial. The Court must merely determine whether defendant's decision to deny plaintiff's claim amounts to an "arbitrary and capricious" application of the Plan's terms to the instant facts.
BACKGROUND
Rosa Close suffered with severe obesity throughout her life. At the time of her death on November 1, 1997, she exceeded her ideal body weight by some 170 lbs., a condition often described as "morbidly obese." On account of her weight, Mrs. Close also suffered dyspena on exertion (difficult and labored breathing), fluid retention, varicose veins, heartburn, hiatal hernia, diabetes mellitus, hyperlipemia (the presence of excess fat in the blood), stress incontinence, and pain in her back, hips, knees and ankles. Def. Ex. 3. Attempting to surgically manage her weight, Rosa Close underwent two prior surgical procedures in 1974 and 1988. Then, in October 1997, Rosa Close again elected to undergo surgery in an effort to reduce her weight.
On October 19, 1997, Mrs. Close was admitted to Addison Community Hospital to undergo a Roux-en-Y gastric exclusion procedure to be performed by Dr. Batay-Csorba. The Roux-en-Y operation bisects the stomach, creating an upper and a lower portion. Part of the intestine is then used to connect the upper portion of the stomach to the jejunal (mid-section) of the small intestine. The place where the connection is made to the jejunal section is called the jejunal anastomosis site. The theory behind the procedure is that reducing the size of the stomach will result in a feeling of satiation after ingesting a small quantity of food, thereby reducing the patient's caloric intake. One risk associated with the procedure, however, is that the anastomosis might disconnect from the stomach or intestine and allow bowel contents to leak into the abdomen causing infection.
The record indicates that this is most likely what happened in Rosa Close's case. The first 20 hours after the surgery were unremarkable, except for low urine output and a gradually increasing heart rate. By the morning of October 20, however, something was clearly amiss. Mrs. Close repeatedly complained of severe abdominal pain, and she was treated for suspected pulmonary dysfunction. By the evening of October 20, Mrs. Close's vital signs had continued to worsen. Her respiratory rate was decreasing and her heart rate was increasing, and she continued to experience abdominal pain and spasms.
At 7:50 a.m. on October 21, 1997, Mrs. Close was transferred to Foote Hospital in Jackson, Michigan, so that its more advanced facilities could evaluate her condition. Upon arrival at Foote, Mrs. Close's vital signs were approaching a critical state. After ruling out the existence of a pulmonary embolism, the admitting physicians performed an emergency scan of Rosa Close's abdomen. The scan revealed free fluid, likely as a result of leakage at the site of her gastro-jejunal anastomosis. Unfortunately for Mrs. Close, her condition had deteriorated to a point where surgical intervention became inadvisable. Despite every measure then possible, Rosa Close died on November 1, 1997, following multisystem organ failure.
A deputy medical examiner for Oakland County, Dr. Bernardo Pacris, M.D., performed an autopsy. He discovered approximately 800 cubic centimeters of fecal-like material and brown purulent fluid in the abdominal cavity, which he suspected came from a leak at the small bow anastomosis site. Dr. Pacris concluded that Rosa Close died of "acute peritonitis due to ruptured (leak) jejunal anastomosis site." He further concluded the manner of death was "accident," and identified "obesity" as a contributory cause. John Maino, M.D., signed the death certificate, largely relying upon Dr. Pacris' findings.
Following his wife's death, Michael Close submitted a request for payment of accidental death benefits to defendant, along with a copy of the hospital records from Foote and Addison Hospitals. Defendant's third-party administrator then hired ChoicePoint, Incorporated, to interview Dr. Batay-Csorba, who had performed the Roux-en-Y procedure. Dr. Batay-Csorba refused to be interviewed, however, and the third-party administrator then contacted Dr. Pacris, who performed the autopsy. Dr. Pacris reiterated his conclusion to defendant that the manner of death was accident with obesity as a contributing cause in a letter dated February 4, 1998.
Continuing its investigation, defendant's administrator hired Dr. James Lewis, a pathologist, to review Rosa Close's medical records. Dr. Lewis replied to defendant's administrator in a letter dated June 30, 1998, in which he expressed a seemingly contradictory conclusion. In the section labeled opinion, Dr. Lewis states, "There is no evidence of trauma. Based on the circumstances surrounding this death, the results of the postmortem examination and toxicological analysis at the time of autopsy, the manner of death is accident." P1. Ex. 1 at D-00025.
Paragraphs later, however, Dr. Lewis concludes that "In my opinion, the manner of death in this case is natural." Id.
Concluding from its investigation that Rosa Close's death was not accidental as defined under the Plan, defendant notified plaintiff that it intended to deny coverage on September 4, 1998. Following the denial, plaintiff appealed the finding to defendant's appeals committee, but the appeal was denied on December 30, 1998. Plaintiff then filed the instant suit.
ANALYSIS
Like many cases that arise under ERISA, the sole issue is whether the plan administrator's decision to deny plaintiff's claim amounts to an "arbitrary and capricious" application of the terms of the Plan's language. The parties do not dispute that the "arbitrary and capricious" standard of review applies. Nevertheless, a fiduciary "must examine the relevant data and articulate a satisfactory explanation for its action including a rational connection between the facts found and the choice made." Lister v. Stark, 942 F.2d 1183, 1188-1189 (7th Cir. 1991) (internal quotations omitted). Under the Plan's terms, defendant (acting through the third party administrator) possesses discretionary power to interpret and administer the Plan, including determinations of whether a participant is entitled to accidental death benefits. See, e.g., Plan at 123, 126. Thus, the Court's inquiry is to determine whether defendant's action reflects a rational connection between the facts then known to defendant's plan administrator and its ultimate decision to deny plaintiff's claim.
Three clauses contained in the Plan are relevant to determining whether defendant justifiably denied plaintiff's claim. First, pursuant to the Plan's Accidental Death and Dismemberment Indemnity clause, the Plan will pay on an accidental death claim as follows:
When injury results in any of the following losses to an Insured Person within days of the date of the accident, the company will pay in one sum the indicated percentage of the Principal Sum for Loss of:
Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%.
Second, the term "injury" is defined in Part I of the Plan as "injury caused by an accident occurring while this policy is in force as to the Insured Person and resulting directly and independently of all other causes of loss covered by this policy." Third, the Plan contains a disease exclusion clause disavowing coverage for "any loss to an Insured Person caused by or resulting from: (2) disease of any kind."
The combination of the above clauses requires plaintiff to satisfy three elements to recover. Plaintiff must first show that an "accident" has occurred. Second, plaintiff must prove that any injury from an accident also resulted "directly and independently of all other causes;" and third, plaintiff must establish that death was not "caused by or resulting from disease of any kind."
A. Was Rosa Close's Death "Accidental"?
The initial question is whether Rosa Close suffered an accidental death as defined under the Plan. Unfortunately, the meaning of either injury or accident under the Plan's language is at best unclear, and at worst, circular. The Accidental Death and Dismemberment Indemnity clause compensates persons insured under the Plan for losses resulting from "injury," a defined term. Turning to the definition of "injury" provided in Part I sheds no light on the question, however. There, `injury" is defined as "injury caused by an accident. . .", but no definition is provided for the term `accident." Yet because the Plan compensates only for injury that results from the occurrence of an accident, defining the term "accident" is the paramount issue. Neither the Plan nor the SPD provides any further guidance, however, and thus the Court turns to the federal common law of ERISA to determine whether the meaning ascribed by defendant to the term "accident" amounts to an unreasonable interpretation of the Plan's language in light of the record. See Johnson v. Eaton Corp., 970 F.2d 1569 (6th Cir. 1992).
Attempting to answer the Court's question, plaintiff engages in an extended analysis of the case law of various jurisdictions and suggests the Court adopt an interpretation of "accident" which reflects the understanding of the average lay person. Formulated as a legal test, plaintiff argues the common understanding of an accident involves two elements. First, plaintiff contends the insured must not have reasonably expected the injury to occur. Second, plaintiff cites Nehra v. Provident Ins. Co., 454 Mich. 110 (1997), for the proposition that there must be some spatial/temporal element leading the average person to conclude that the death or injury was "accidental" — that is, that the cause of death did not progress over a long period of time.
Applying his proposed test to the record, plaintiff concludes that Rosa Close's death, caused by a rupture of the anastomosis site which led to peritonitis and sepsis can only be reasonably understood to be accidental. Plaintiff relies primarily upon Dr. Pacris' autopsy report and the death certificate signed by Dr. John Maino, M.D. Contending the certificate and report provide unbiased, and thus superior evidence when compared with the forensic report of Dr. Lewis (relied upon by defendant), plaintiff urges the Court to find Rosa Close's death was accidental.
Defendant disagrees, and citing Senkier v. Hartford Life Accident Ins. Co., 948 F.2d 1050 (7th Cir. 1991), argues first that death from consensual non-emergency medical treatment is not "accidental" under ERISA law, because given the consent form and natural risks of surgery, the risk of death was foreseeable.
The plaintiff in Senkier was admitted to a hospital with a diagnosis of intestinal obstruction. A catheter was inserted in a vein beneath her clavicle for the purpose of administering nourishment intravenously, standard treatment for her condition. Several days later she died suddenly, and it was later discovered that the catheter had become detached from its original position and punctured the plaintiff's heart. Senkier, 948 F.2d at 1051. Addressing the question of whether the plaintiff had died as a result of accident or from sickness, the Seventh Circuit concluded that "Medical treatment is often risky and when the risk materializes and the patient dies we do not call it dying in or because of an accident; it is death from sickness." Id. at 1053.
Plaintiff attempts to distinguish Senkier, arguing the issue addressed there was whether an insured's death during surgery-whether accidental or otherwise-must still be excluded under a "surgical treatment exclusion."
Having carefully compared the relevant precedents with the record, in particular the Seventh Circuit's holding in Senkier, the Court concludes defendant's decision to deny benefits did not amount to arbitrary and capricious action. Furthermore, the Court does not agree with plaintiff's characterization of the issue in Senkier, and finds plaintiff's distinction is not supported by the subsequent case law he cites. Two considerations guide this Court's analysis. First, the Court does not review the record de novo, but rather employs the more relaxed arbitrary and capricious standard of review. Second, Senkier is factually analogous to the case at bar, and thus is convincing persuasive authority. In contrast, the cases cited by plaintiff are factually distinguishable, and the Court does not agree that plaintiff's cases serve to limit Senkier's holding as he contends.
Consequently, despite the credible opinions of Drs. Pacris and Maino determining Rosa Close's death to be accidental, the Court cannot base its legal conclusion as to the nature of Mrs. Close's death merely by weighing the opinions of physicians, however unbiased. The Court is not free to elect between competing notions of what constitutes an "accident" under ERSIA. Rather, under the arbitrary and capricious standard of review, the Court's inquiry is limited to determining whether defendant's interpretation of the term accident under these facts is reasonable or plausible. See Wendy's Int'l., Inc. v. Karsko, 94 F.3d 1010, 1012 (6th Cir. 1996); see also Cozzie v. Metropolitan Life Ins. Co., 140 F.3d 1104, 1109-1110 (7th Cir. 1998). After carefully reviewing the record, the Court concludes defendant's interpretation of the Plan's Accidental Death and Dismemberment Indemnity was not arbitrary and capricious.
B. Did Rosa Close's Death Result "Directly and Independently" of Pall Other Causes?
Were the Court to have determined that Rosa Close's death was accidental in nature, it would still be necessary to determine whether her death resulted "directly and independently of all other causes of loss covered under this policy," and whether her death was "caused by or resulting from disease of any kind." Because the Court finds that even were Rosa Close's death properly characterized as accidental, its findings on these issues would stand as an independent bar to plaintiff's recovery. Accordingly, the Court takes up these issues below.
Plaintiff focuses on the meaning of "directly and independently" as the phrase has developed in the case law and asserts that the Sixth Circuit adopted an approach first presented in Adkins v. Reliance Standard Life Ins. Co., 917 F.2d 794 (4th Cir. 1990), in an unpublished decision, Tolley v. Commercial Life Ins. Co., 14 F.3d 602, 1993 WL 524284 (6th Cir. 1993). Tolley approved of the Adkins approach and held that "coverage for losses `resulting directly and independently of all other causes from bodily injury caused by accident' does not exclude preexisting infirmity or disease unless the infirmity `substantially contributed to disability or loss.'" Tolley, 1993 WL 524284 at *3. Plaintiff then proceeds to distill the issue as follows: "Remembering that the injury which lead [sic] to Rosa Close's death was a leaking anastomosis and resulting fatal peritonitis, the question becomes whether Rosa Close had a pre-existing condition, predisposition, or susceptibility to such a leaking anastomosis."
In stark contrast to plaintiff's position, defendant maintains that even a cursory examination of Mrs. Close's medical history demonstrates that her morbid obesity contributed to and was a factor in her death. Noting that Mrs. Close twice before underwent surgery in unsuccessful attempts to treat her weight condition, defendant contends her obesity and concomitant health problems were contributing causes of her death.
At oral argument, the parties continued to dispute vigorously the role obesity played in Rosa Close's death, a question of fact for which the Court can find no clear answer in the record. The record does reflect, however, that the physician who performed the autopsy, Dr. Pacris, identified "obesity" as a "contributing cause" of Rosa Close's death in his autopsy report. Def. Ex. 12. Faced with this evidence alone, the Court would be hard pressed to adjudge defendant's determination unreasonable.
In addition, the Court finds plaintiff's framing of the issue incorrectly presents the issue as whether Rosa Close had a predisposition to suffer a rupture at her anastomosis site. The proper line of inquiry as developed in subsequent Fourth Circuit case law (as acknowledged by plaintiffs), however, is "First, whether there is a pre-existing disease, pre-disposition, or susceptibility to injury; and second, whether this pre-existing condition, pre-disposition or susceptibility substantially contributed to the disability or loss." Q uesinberry v. Life Ins. Co., of North America, 987 F.2d 1017, 1028 (4th Cir. 1993). Prior to undergoing the Roux-en-Y procedure, Rosa Close suffered morbid obesity as a pre-existing condition. Hence, assuming Tolley represents the proper analytical approach, the issue is whether Rosa Close's morbid obesity "substantially contributed" to her unsuccessful surgery and death, and not whether she suffered a predisposition to the occurrence of anastomotic leakage.
In analyzing this issue, the Court concludes defendant's position is correct given the arbitrary and capricious standard of review. Although the administrative record is not well-developed, defendant's position is not without support. It is undisputed that Rosa Close suffered from a pre-existing disease, namely morbid obesity, and as a result, suffered numerous attendant ailments. Although the mere fact that Mrs. Close sought surgery to control her weight is insufficient to find her obesity was a contributing factor to her demise, plaintiff has not adduced any evidence to suggest pre-existing morbid obesity was not a contributing factor in Rosa Close's death.
By contrast, defendant adduces the report of Dr. Pacris, the Deputy Medical Examiner, who expressly identified obesity as a contributing cause in Mrs. Close's death. And although the June 30, 1998 report of defendant's forensic pathologist Dr. Lewis is not a model of clarity, it does conclude that "[a]ny and all pathology leading up to [Rosa Close's] death was a natural occurrence secondary to her preexisting disease states or pathology." Def. Ex. 15. Furthermore, the record does not present any evidence of therapeutic misadventure or medical malpractice that would negate a finding that Mrs. Close's obesity contributed to her demise. Consequently, in light of the above evidence from the record, the Court concludes the denial of benefits was not unreasonable or arbitrary and capricious.
CONCLUSION
This case is typical of many ERISA cases that come before the Court in that it presents hard questions of fact involving conflicting medical interpretations. The Court is not unsympathetic with plaintiff's perspective; however, the Court concludes defendant's actions were not arbitrary or capricious. Accordingly, judgment will be entered for defendant.
JUDGMENT ORDER
In accordance with the Court's memorandum opinion of even date finding that defendant's denial of plaintiff's claim for accidental death benefits under its Employee Accidental Death and Dismemberment Benefits Plan was not arbitrary and capricious now, therefore,
IT IS HEREBY ORDERED that JUDGMENT IS AWARDED TO DEFENDANT and against plaintiffs on all counts of plaintiff's complaint.
Dated: May 31, 2000
DAVID W. McKEAGUE UNITED STATES DISTRICT JUDGE