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Hetty A. Viera v. Life Insurance Company of North America

June 10, 2011

HETTY A. VIERA, AS EXECUTRIX OF THE ESTATE OF FREDERICK A. VIERA; HETTY A. VIERA, INDIVIDUALLY, APPELLANTS
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA



On Appeal from the United States District Court for the Eastern District of Pennsylvania (D.C. No. 2-09-cv-03574) District Judge: Honorable Eduardo C. Robreno

The opinion of the court was delivered by: Fisher, Circuit Judge.

PRECEDENTIAL

Argued April 13, 2011

Before: FISHER, JORDAN and COWEN, Circuit Judges.

OPINION OF THE COURT

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. Viera‟s wife and the executrix of his estate, Hetty Viera ("Plaintiff"), submitted a claim under the Policy following his death. LINA denied Plaintiff‟s 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 policy regulated under ERISA.*fn1 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 anti- coagulant 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*fn2 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 ...


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