United States District Court, M.D. Pennsylvania
RYTA CHANTHAVONG and BRIAN CHANTHAVONG as legal guardians of D.D.C., a minor, Plaintiffs
UNION SECURITY INSURANCE COMPANY d/b/a ASSURANT EMPLOYEE BENEFITS, Defendant
For Ryta Chanthavong, as legal guardians of D.D.C., a minor, Brian Chanthavong, as legal guardians of D.D.C., a minor, Plaintiffs: Raymond W. Ferrario, LEAD ATTORNEY, Scranton, PA.
For Union Security Insurance Company, d/b/a Assurant Employee Benefits, Defendant: Heather J. Austin, Wilson Elser Moskowitz Edelman & Dicker, LLP, Philadelphia, PA.
JAMES M. MUNLEY, United States District Judge.
Before the court for disposition are cross motions for summary judgment filed by both the defendant (Doc. 18) and plaintiffs (Doc. 16). These motions are fully briefed and ripe for disposition. For the reasons stated below, the court will deny defendant's motion and grant summary judgment in favor of the plaintiffs.
The instant case presents a dispute over the interpretation of a life insurance policy with an accidental death benefit. Specifically, the parties disagree as to whether a policy exclusion, providing that no benefit will be paid when an accidental death is caused, directly or indirectly, by a disease, applies.
Cory D. Carter died on April 14, 2012, accidentally drowning in his bathtub. (Compl. ¶ 11). The insurance company, Defendant Union Security Insurance (hereinafter " defendant" ), denied the plaintiffs' request for the accidental death benefit. Defendant maintains that Carter's death was caused in part, indirectly or directly, by a seizure disorder, which renders the benefit unpayable. Plaintiffs argue that defendant's denial was based upon an incorrect interpretation of the policy, and that defendant's finding that Carter had a seizure was unsubstantiated.
A. The Policy
Carter was insured under a group life insurance policy established by his employer, Scranton Dunlop, Inc., which did business as Sandone Tire and Battery, Inc. (Doc 1, Compl. ¶ ¶ 5, 8). Carter listed his minor son, Plaintiff D.D.C., as the policy's beneficiary in the event of Carter's death. (Id. ¶ 8).
The policy, number G 5457895, which includes a general life insurance benefit as well as accidental death coverage, states that Pennsylvania law governs its interpretation. (Doc. 18-3, Group Insurance Policy at 2). The policy contains an " Exclusions" provision stating that defendant " will not pay [accidental death] benefits if the loss results directly or indirectly from . . . any physical disease . . . ." (Id. at 26). The accidental death life insurance group plan at issue is established and maintained as an employee benefit plan, and as such is subject to the provisions of the Employee Retirement Income Security Act of 1973 (hereinafter " ERISA" ), 29 U.S.C. § 1001, et seq. Pursuant to § 502(a) of ERISA, 20 U.S.C. § 1132, a beneficiary of an employee plan may bring a civil action to recover benefits due him under the terms of the plan.
B. The Claims Process
In the wake of Carter's death, the plaintiffs filed claims for benefits under the general life insurance and accidental death insurance provisions of the policy, each of which provided for payouts of $100,000. Defendant paid the $100,000 general life insurance proceeds (plus $1 in interest) into an account for the benefit of Plaintiff D.D.C. on May 25, 2012. (Doc. 18-3, Assurant Letter dated 5/25/12 at 83). Defendant denied the accidental death claim on October 23, 2012, asserting that Carter's seizure disorder triggered the physical disease exclusion under the accidental death policy. (Doc. 18-3, Assurant Letter dated 10/23/12 at 145).
Through counsel, plaintiff invoked defendant's internal appeal process on December 13, 2012. Plaintiff argued that the accidental death benefit should be paid because Carter's death was caused by drowning, cardio-pulmonary arrest, and respiratory failure. (Doc. 18-3, Plaintiff Appeal Letter dated 12/13/12 at 156-57). In denying plaintiffs' appeal, defendant acknowledged the accidental nature of Carter's death, but stated that because a seizure caused the drowning, the physical disease exclusion applied, precluding payment of the accidental death benefit. (Doc. 18-3, Assurant Letter dated 1/22/13 at 208-209).
Plaintiffs indicated they would further appeal on January 30, 2013. (Doc. 18-3, Plaintiffs' Appeal Letter at 215). After an internal committee reviewed the case file, defendant again denied plaintiffs' appeal, finding that Carter's seizure disorder indirectly caused his death. (Doc. 18-3, Assurant Letter dated 4/15/13 at 229).
C. Medical Evidence
Lackawanna County Coroner Timothy Rowland issued a certificate of death that listed cause of death as drowning and seizure disorder, and manner of death as accidental. (See Doc. 18-3, Clinical Services Assessment at 86; Doc. 18-4, Coroner Summary Report at 149). Gary W. Ross, M.D., a forensic pathologist at Forensic Associates of NEPA, performed an autopsy on April 16, 2012. (Doc. 18-3, Dr. Gary Ross Autopsy at 160-171). In a report dated June 18, 2012, Dr. Ross noted Carter's history of seizure disorder, and found no evidence of external traumatic injury. (Id.) The lungs were reportedly wet and heavy, and Dr. Ross found a bloody froth in the bronchi and trachea. (Id.) Carter had a blood/alcohol level of .035 at death, and evidence of marijuana use was found. (Id.) Dr. Ross listed the cause of death as " [d]rowning due to seizure disorder," and manner of death was " accidental." (Id.)
On June 29, 2012, after plaintiffs submitted their initial claim, pathologist Allen J. Parmet, M.D., at the defendant's behest, reviewed available documents (which did not include any of Carter's medical records (see Doc. 18-4 at 73-74)) and concluded that Carter was non-compliant with medical therapy and had died as a direct result of a seizure. (Doc. 18-4, Assurant Letter dated 4/15/13 at 2).
As part of the first appeal, Michael D. Bell, M.D., a pathologist engaged by the defendant, reviewed the case, including Dr. Parmet's findings. He found that Carter's drowning was " the direct result of his untreated seizure disorder." ...