The opinion of the court was delivered by: Eduardo C. Robreno, J.
Plaintiff Hetty Viera ("Plaintiff") brings this ERISA action against Defendant Life Insurance Company of North America ("LINA") seeking payment of benefits under an accidental death and dismemberment policy arising from the death of her husband. Before the Court are cross-motions for summary judgment. For the reasons that follow, Defendant's motion for summary judgment will be granted and Plaintiff's motion for summary judgment will be denied.
This action arises pursuant to the Employee Retirement Income and Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B).*fn1
On October 14, 2008, Frederick Viera ("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, LLC. These insurance policies consisted of an employer-provided life insurance policy, and an employer-provided accidental death and dismemberment policy (the "AD & D Policy"). The claims administrator for each of these policies is Defendant LINA. Only the AD & D Policy is the subject of the instant litigation.
Viera had a pre-existing chronic condition known as atrial fibrillation prior to LINA's issuing the AD & D Policy. (Def.'s Mot. Summ. J. Ex. C 123-25, 210.) As part of the medical treatment for his atrial fibrillation, Viera received a medication called Coumadin (also known as Warfarin).*fn2 (See id. 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 LINA, but this claim was denied.*fn3 LINA's position is that Viera's death was not a covered event under the express terms of the AD & D Policy.
The relevant provisions of the AD & D Policy are as follows:
- "Covered Loss," defined 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.
- "Covered Accident," defined 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.) LINA does not contest that death represents a "Covered Loss" or that Plaintiff satisfies the criteria as a "Covered Person" under the AD & D Policy.
The AD & D Policy contains a provision that specifically excludes a claim for benefits "which, directly or indirectly, in whole or in part, is caused by or results from . . . [s]ickness, 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. 32.) LINA contends that this medical condition exclusion (the "Medical Condition Exclusion") dictates that Viera's loss was excluded from coverage under the AD & D Policy. More specifically, LINA denied Plaintiff's benefit claim on the ground that Plaintiff's Coumadin treatment complicated Viera's medical treatment and constituted a contributing factor to his death after his accident.
On July 10, 2009, Plaintiff commenced this action by filing a complaint in the Court of Common Pleas of Philadelphia County, Pennsylvania. On August 5, 2009, Defendant removed the action to this Court pursuant to 28 U.S.C. §§ 1331 and 1441. Plaintiff filed an amended complaint on October 16, 2009. Pursuant to a scheduling order issued by the Court, Defendant and Plaintiff filed motions for summary ...