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Hepler v. Transamerica Premier Life Insurance Co.

United States District Court, W.D. Pennsylvania

September 30, 2019

CHRISTOPHER T. HEPLER, as Executor of the Estate of Wallace D. Hepler, Jr., Deceased, Plaintiff


          Alan N. Bloch United States District Judge

         AND NOW, this 30th day of September, 2019, in consideration of Defendant’s Renewed Motion for Judgment on the Pleadings (Doc. No. 47) and memorandum and exhibits in support thereof (Doc. Nos. 47-1 through 47-4), filed in the above-captioned matter on December 18, 2018, and in further consideration of Plaintiff’s Response in Opposition and brief in support thereof (Doc. Nos. 53 and 54), filed on January 16, 2019, as well as Defendant’s reply (Doc. No. 57) filed January 30, 2019 (Doc. No. 57), IT IS HEREBY ORDERED that, for the reasons set forth herein, Defendant’s Motion is GRANTED. Accordingly, Plaintiff’s Amended Complaint (Doc. No. 25) is DISMISSED.

         I. Background

         A. General

         This case arises from the death of Betty Jo Hepler. At the time of Ms. Hepler’s death, she was insured under Accidental Death and Dismemberment Policy No. MZ0932692H0001F, Coverage Identification No. 742323344 (the “Policy”), issued by Defendant Transamerica Premier Life Insurance Company (“Defendant” or “Transamerica”). The Policy provided accidental death benefits in the amount of $300, 000.00, and Ms. Hepler’s husband, Plaintiff Wallace D. Hepler, was the named beneficiary under the Policy.[1] After Ms. Hepler died, Plaintiff applied for benefits, but Transamerica denied his application on the basis that conditions other than an accident contributed to Ms. Hepler’s death. After attempting to resolve the matter with Defendant, Plaintiff brought the instant action.

         B. Plaintiff’s Original Complaint

         Plaintiff filed his original complaint on November 1, 2017. In the complaint, Plaintiff alleged that, on July 26, 2014, his wife, Ms. Hepler fell from a standing position in her home, and was later diagnosed with a right supracondylar femur fracture with posterior displacement of a distal fracture fragment. He stated that Ms. Hepler underwent an open reduction internal fixation on her right femur two days later at UPMC Hamot in Erie, Pennsylvania. After an extended stay at Hamot, she was then transported UPMC Northwest Rehabilitation Hospital on July 25, 2014. Plaintiff asserted that, because Ms. Hepler was unable to tolerate the rehabilitation program at UPMC Northwest, she was transferred to Oakwood Heights Nursing Home on July 31, 2014. She remained non-weight bearing while there and required maximum assistance with her activities of daily living. She followed up with her surgeon and was found to have further displacement of the distal fracture fragment, but was deemed a non-operative candidate. Ms. Hepler died on November 24, 2014. (Complaint, Doc. No. 1 (“Compl.”) at ¶¶ 16-25).

         Plaintiff asserted, as discussed above, that Ms. Hepler was insured by Transamerica under the Policy for accidental death, and that he was the beneficiary. He stated that he and his wife had paid $148.50 quarterly to keep the Policy effective, as required, and that the Policy, therefore was in effect at the time of Ms. Hepler’s death. (Compl. at ¶¶ 5-15). Plaintiff further asserted that his wife’s accidental fall was “the precipitating factor in her death” (Compl. at ¶ 27) and sought benefits under the Policy’s Insuring Clause, which provides:

When we receive due proof that a Covered Person dies, we will pay the benefit shown on the Schedule to his named Beneficiary; provided death occurs as a direct result of an injury.

(Compl., Ex. A at 5). Injury is defined, in relevant part, as “accidental bodily injury sustained by the Covered Person, which is the direct and independent cause of Loss.” (Id. at 6). Plaintiff contended that this standard was met in this instance. Transamerica denied his application, asserting that his claim was barred by the Policy’s Exclusionary Clause, which provides that Transamerica “will not pay a benefit for a Loss which is caused by, results from, or contributed to by” eight specific conditions. One of these conditions is “Sickness or its medical or surgical treatment, including diagnosis.” (Id. at 5). It has asserted that Ms. Hepler had a number of “sicknesses” that contributed to her death. Plaintiff asked Transamerica to reconsider, but it declined. (Compl. at ¶¶ 26-40). Plaintiff filed his complaint, attaching a number of documents, including a copy of the Policy, and a report from Todd M. Luckasevic, D.O., indicating that it was his opinion that Ms. Hepler’s fall was the major contributory factor in her death.

         On January 24, 2018, Defendant moved for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c), arguing that the language of the Policy’s Exclusionary Clause required Plaintiff to establish that sickness did not contribute to Ms. Hepler’s death. It asserted that Plaintiffs claim that his wife’s accident was a precipitating or major contributory factor to her death was insufficient to meet this standard. Plaintiff disagreed and argued that he only needed to establish that accidental causes were the proximate cause of Ms. Hepler’s death. After oral argument on April 3, 2018, the Honorable Mark R. Hornak granted Defendant’s motion for judgment on the pleadings, holding that the Exclusionary Clause in the Policy made this a “two-step” case which required Plaintiff to plead (and establish) more than just proximate cause.[2] Judge Hornak provided Plaintiff with 30 days to amend his complaint.[3]

         C. Plaintiff’s Amended Complaint

         Plaintiff filed his Amended Complaint, which is presently before the Court, on May 3, 2018. As with the original complaint, Plaintiff asserts in the Amended Complaint that this Court has jurisdiction pursuant to 28 U.S.C. § 1332 since the amount in controversy is in excess of $75, 000.00, and there is diversity of citizenship between the parties. (Amended Complaint, Doc. No. 25 (“Am. Compl.”) at ¶ 1). The factual allegations of the Amended Complaint are substantially similar to those of the original complaint, as discussed above. (Id. at ¶¶ 5-37).[4]However, in light of Judge Hornak’s prior ruling, Plaintiff raises not one but two counts for breach of contract, one for breach under a “one-step” causation standard (Count One) and one for breach under a “two-step” standard (Count Two). In Count One, while acknowledging Judge Hornak’s ruling that the Policy’s Exclusionary Clause makes this a two-step case, Plaintiff now alleges that “the Policy’s exclusionary provision is unenforceable against the Plaintiff, as it is unconscionable, unfair and unduly restrictive and in violation of 31 Pa. Code § 90d.4.” (Id. at ¶ 39). He asserts, therefore, that the Policy should be deemed to be a one-step policy, requiring only a showing of proximate cause, and he states that Ms. Hepler’s accident was, in fact, the proximate cause of her death, which he contends is sufficient to establish liability.

         In Count Two, Plaintiff states that Ms. Hepler died “as a direct and independent result of her accidental fall and her death was not caused by, resulted from, or contributed to by a sickness or its medical or surgical treatment, including diagnosis.” (Id. at ¶ 46). While such a claim may satisfy a two-step standard, as was discussed extensively at the April 3, 2018 hearing before Judge Hornak, Dr. Luckasevic’s opinion is not really consistent with such a claim. Accordingly, during an October 11, 2018 telephonic status conference with Judge Baxter, Plaintiff ...

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