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Hetty A. Viera, As the Executrix of the Estate of Frederick A. Viera, and Hetty v. Life Insurance Company of North America

August 3, 2012

HETTY A. VIERA, AS THE EXECUTRIX OF THE ESTATE OF FREDERICK A. VIERA, AND HETTY A. VIERA, INDIVIDUALLY, : PLAINTIFF,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, DEFENDANT.



The opinion of the court was delivered by: Eduardo C. Robreno, J.

MEMORANDUM

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) seeking payment of benefits under an accidental death and dismemberment policy arising from the death of her husband Frederick Viera ("Viera").*fn1 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 briefly treated at St. Mary's Hospital and Medical Center and was subsequently pronounced dead. Defendant Life Insurance Company of North America ("Defendant") denied benefits under an accidental death and dismemberment policy.

Following a bench trial and pursuant to Federal Rule of Civil Procedure 52(a), this Memorandum constitutes the Court's findings of fact and conclusions of law. For the reasons that follow, the Court will grant judgment in favor of Plaintiff.

II. PROCEDURAL BACKGROUND

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 Plaintiff's motion for summary judgment. In doing so, the Court evaluated Defendant's denial of benefits under the deferential abuse of discretion standard because 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). The parties submitted competing medical expert opinions on Viera's cause of death. Under the abuse of discretion standard, the Court found no abuse of discretion when the administrator chose to credit one medical opinion over another. 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"). 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 of the blood thinner Coumadin® ("Coumadin").*fn2 Id. at *7-8.

In addition, the Court denied Plaintiff's motion for summary judgment based upon an interpretation of the accidental death and dismemberment policy. Specifically, the Court held that a medical condition exclusion in this 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 Plaintiff's 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 the case, the Court held a status and scheduling conference. At that conference, the Court ordered the parties to submit briefing on how the Court was to conduct this de novo review. The Court issued a memorandum and order concluding that the current administrative record was sufficient, along with the parties' experts' reports and video trial deposition cross-examination of those experts, to conduct its de novo review. See Order, May 14, 2012, ECF No. 50; Mem. Op., May 14, 2012, ECF No. 49; Order, June 6, 2012, ECF No. 58. The Court held a bench trial at the conclusion of which it heard closing argument. The Court has reviewed all of the admitted evidence in this case: the Administrative Record, the expert opinions of Drs. Mark Eaton and Aaron Gindea, and the video trial depositions of Drs. Mark Eaton and Aaron Gindea.*fn3 Upon this record, the Court now conducts its de novo review.

III. FINDINGS OF FACT

A. Background

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. R. at 209-10.*fn4

These insurance policies consisted of an employer-provided life insurance policy, No. FLX 960990, R. at 231-262, and an employer-provided accidental death and dismemberment policy (the "AD & D Policy" or the "Policy"), No. OK961030. R. at 11-43. The claims administrator for each of these policies is Defendant. Only the AD & D Policy is the subject of the instant litigation.

Viera had a pre-existing medical condition known as atrial fibrillation before Defendant issued the AD & D Policy.

As part of the medical treatment for his atrial fibrillation, Viera received a medication called Coumadin. See id. at 135-38.

B. Viera's Motorcycle Accident

On October 14, 2008, Viera was involved in a head-on motorcycle versus car 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.

C. Treatment at St. Mary's Hospital

Plaintiff's treatment was extensive. Upon arrival at St. Mary's, Plaintiff received four units of fresh frozen plasma, along with vitamin K. R. at 85. During the course of his treatment, Plaintiff received an additional four units of fresh frozen plasma and eight units of blood, along with some medicines. Upon arrival in the emergency room, Viera's INR was 2.8.*fn5 R. at 87. Viera also had an APTT of 41 at the time of his admittance to the emergency room.*fn6 Approximately two hours after Viera began treatment at St. Mary's, his INR was 2.9, and his APTT was 187. R. at 87. This APTT was noted on his laboratory report as a "critical value." R. at 88. Over this same time, several of Viera's other blood values fell from a normal value to a low value.*fn7 R. at 87.

It was determined that Viera had incurred numerous injuries from his head-on motorcycle accident. The lead emergency room physician was Dr. Michael Bradshaw. Dr. Bradshaw reported in the "Death Summary" that Viera suffered multiple pelvic fractures, complex fractured nerves and blood vessels in the pelvic area, lacerated iliac arteries, "significant bruising and swelling in the pubic region and pelvic area[,] [h]is left knee was extremely loose and contused[,] [and] [h]is left foot was extremely contused and misshapen." R. at 84-85. Viera's injuries were such that he could not move his lower body. R. at 85. A surgeon "embolized" both internal iliac arteries and observed there was "active brisk bleeding from the right internal iliac distribution." Id.

Dr. Bradshaw noted that throughout Viera's treatment his blood pressure was generally unstable. Although Viera's blood pressure became more stable after the embolization of the iliac arteries, it soon began to drop again. Id. After Viera again became unstable, emergency room physicians were unable to revive him and he passed away at 7:51 p.m. Dr. Bradshaw's "Final Diagnosis" was as follows: "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. He eventually expired because of unresponsiveness to blood pressure and cardiac output." R. at 86. A reviewing physician, Dr. David James, provided this assessment of Viera's condition: "Severe injuries including bleeding pelvic fractures being embolized. Very poor perfusion ...


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