By Pension and Benefits Editorial Staff
An insurer did not abuse its discretion in denying accidental death benefits to a widow whose husband died in an automobile accident, the U.S. Court of Appeals for the First Circuit ruled, finding that substantial evidence supported the insurer’s conclusion that the insured’s preexisting medical conditions caused or contributed to his death.
The insured, a sales executive, was 57 years old at the time of the accident and had been suffering from several medical conditions, including obesity, hypertension, hypertrophic cardiomyopathy (heart enlargement associated with arrhythmias and heart failure), anxiety, depression, and fainting spells. Approximately four months prior to the accident, he had an episode in which he felt weak, vomited, and fainted. As a result, he had an implantable cardioverter defibrillator (ICD) placed in his chest that monitored his heart rate and rhythm and could administer electric shocks to restore normal heart rhythm if necessary.
On the day of the accident, the insured was driving to a work-related event when his car crossed the highway median into oncoming traffic and struck another vehicle, causing his car to flip over several times before landing upright. Eyewitnesses reported that he was briefly alive following the accident but that he quickly succumbed to his injuries. He was pronounced dead at the scene. The insured’s widow filed a claim for accidental death benefits, but the insurer, Zurich American Insurance Company, denied her claim on the grounds that the insured’s death was not independent of all other causes and was caused or contributed to by his preexisting health conditions. The district court ruled in favor of the widow, and Zurich appealed.
Policy provisions. The accidental death policy, which was governed by ERISA, stated that Zurich would pay benefits “[i]f an Insured suffers a loss of life as a result of a Covered Injury.” The term “Covered Injury” was defined as “an injury directly caused by accidental means which is independent of all other causes.” The policy excluded coverage if a loss was caused or contributed to by an illness or disease.
Evidence in the record. An autopsy report concluded that the cause of the insured’s death was hypertensive heart disease and that a contributory factor was “Upper Cervical Spine Fracture due to Blunt Impact.” The death certificate listed the same primary cause of death. In addition, based on preliminary autopsy reports and interviews with witnesses, one of whom said that the insured “went into breathing distress and started to seize” before losing consciousness, the state police concluded that the insured “experienced some type of medical episode while driving his vehicle.” In a collision reconstruction report, a police officer ruled out various other causes of the accident, such as poor road conditions, mechanical failure, engineering design flaws in the road, and speeding. The officer concluded that the insured “had suffered a catastrophic medical event which caused him to be unable to control his vehicle.” An independent medical reviewer hired by Zurich also opined that the insured’s crash and death were caused by his heart disease.
In appealing Zurich’s initial denial of coverage, the widow submitted a logbook from the ICD’s manufacturer, but she did not provide an explanation of how to interpret it. She supplemented her appeal with an independent medical review from a forensic pathologist, who opined that the insured did not experience “a natural death at the wheel” with a resulting collision. The pathologist also commented that because the ICD logbook “showed no abnormal heart rhythms recorded prior to the collision,” the accident was not caused by “incapacitation by heart disease.”
In response, Zurich retained its own forensic pathologist, who ruled out several possible causes of the accident, such as suicide. He concluded that the accident was caused by several possible preexisting illnesses or diseases, singly or in combination, including: (1) cardiac arrhythmia resulting from preexisting heart disease; (2) an adverse reaction to heart medication; and (3) medication-related blood pressure problems. Zurich’s pathologist did not consider the ICD logbook in reaching his conclusion. Taking all this information into account, the appeals committee upheld Zurich’s initial denial.
District court decision. The district court held that Zurich’s denial of benefits was arbitrary and capricious because the evidence showed only that the insured had a history of heart disease—not that heart disease was the cause of his death. The lower court also pointed out that Zurich’s pathologist could not identify which preexisting medical condition occurred during the pre-collision phase of the accident that resulted in fatal bodily injuries. The court did not focus on the policy’s “contributed to” language.
Contributing cause of death. According to the appellate panel, the descriptions in the record of the causes that contributed to the insured’s death were all consistent with the conclusion that the crash was caused, at least in part, or was contributed to, by his preexisting medical conditions. Taking into account all the evidence and medical opinions as a whole, Zurich’s conclusion was not undermined simply because the opinion of the widow’s pathologist differed. Although that pathologist said it was impossible to tell with “a reasonable degree of medical certainty” that the insured’s preexisting medical conditions contributed to his having the accident that resulted in his death, Zurich reasonably could rely on its own pathologist’s opinion “to a reasonable degree of forensic medical certainty” that this is exactly what happened. Moreover, even though Zurich’s pathologist did not specify exactly which of the preexisting pathologies—singly or in combination with others—provided the precise contribution, this did not negate his ultimate conclusion. Rather, it reinforced the care with which he analyzed the data before reaching his conclusion, the court reasoned.
Contrary to the dissenting judge’s opinion, Zurich was not required to rely on the ICD logbook. According to the majority, Zurich reasonably interpreted the logbook as inconclusive, a view that was supported by the record. For example, the logbook did not record anything after the last “rhythm update” 75 minutes prior to the accident, and it failed to record the stopping of the insured’s heartbeat upon his death, an indication that it was not working properly. Nor was Zurich required to accept the interpretation of the logbook proffered by the widow’s pathologist, as her opinion was found to contain deficiencies.
In sum, Zurich’s decision was supported by substantial evidence and, thus, was not arbitrary or capricious, the panel concluded, reversing the lower court.
SOURCE: Arruda v. Zurich American Insurance Co., (CA-1), No. 19-1247, February 24, 2020.
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