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Silvers v. CCPOA Benefit Trust Health and Welfare Plan

April 14, 2009


The opinion of the court was delivered by: Frank C. Damrell, Jr. United States District Judge


This matter is before the court on the parties' cross-motions for summary judgment, pursuant to Federal Rule of Civil Procedure 52, arising out of defendant CCPOA Benefit Trust Health and Welfare Plan's ("defendant" or "the Plan") denial of plaintiff Judith Lourene Silvers' ("plaintiff" or "Mrs. Silvers") claim for accidental death benefits.*fn1

For the reasons set forth below, the court finds that the proper standard of review is de novo, and thereunder, the court finds that plaintiff has not met her burden in showing that her husband's death "resulted from" the hip injury he suffered ten months prior to his death. As such, the court DENIES plaintiff's motion for summary judgment and GRANTS defendant's motion.


Plaintiff's husband, Hal Silvers ("Mr. Silvers"), deceased, was insured under a group accidental death and dismemberment policy ("the policy") through his union, the California Correctional Peace Officers Association ("CCPOA"). Hartford Life and Accident Insurance Company ("Hartford") issued and administered the policy, which covers retired members of the CCPOA. (Ex. A to First Am. Compl. ("Hartford Certificate of Insurance"), filed Feb. 21, 2008.) Mr. Silvers designated his wife, Judith Lourene Silvers, as his beneficiary. (Id.)

The policy states in pertinent part: "If a Covered Person's injury results in any of the following losses within 365 days after the date of the accident, we will pay the sum shown opposite the loss. . . . For Loss of: Life . . . The Principal Sum." (Ex. A to Decl. of Richard Davis ("Administrative Record"), filed Sept. 15, 2008, at H057.) "Injury" is defined in the policy as: bodily injury resulting directly and independently of all other causes from accident which occurs while [the covered person] is covered under this policy. Loss resulting from:

a) sickness or disease, except a pus-forming infection which occurs through an accidental wound; or

b) medical or surgical treatment of a sickness or disease; is not considered as resulting from injury. (Hartford Certificate of Insurance; Administrative Record at H052.)

On May 7, 2003, Mr. Silvers fell at home while undressing to go to bed. (Administrative Record, at H070.) Mr. Silvers, age sixty-five, went to the Redding Medical Center Emergency Department ("the hospital") complaining of left hip and lower back pain. (Id.) Dr. Andrew Knapp examined Mr. Silvers, noting that Mr. Silvers "smokes a pack of cigarettes per day" and "drinks alcohol daily." (Id.) Dr. Knapp further noted that Mr. Silvers had a history of hypertension, osteoporosis, and arthritis and that he was on numerous medications, including "Xanax, Altrace, hydrochlorothiazide, prednisone, and codeine." (Id.) Dr. Knapp's physical examination revealed that the patient's "[l]ungs were clear of auscultation" and that he had a regular heart rate and rhythm. (Id.) Mr. Silvers was diagnosed with a hip fracture and admitted to the hospital under the care of Dr. Dale Adishian in orthopedics. (Id. at H071-72.)

Dr. Adishian examined Mr. Silvers later that same day. (Id. at H081-83.) Dr. Adishian reported that Mr. Silvers had been drinking prior to his fall and that Mr. Silvers had chronic obstructive pulmonary disease ("COPD") and hypertension. (Id. at H081.) According to the report, Mr. Silvers denied "any difficulty with ambulation" other than becoming short of breath. (Id.) Dr. Adishian recommended surgery to stabilize Mr. Silvers' left hip. (Id.)

Prior to the surgery, Dr. Adishian referred Mr. Silvers to Dr. Than Aung for review of Mr. Silvers' electrolyte imbalance.

(Id. at 134.) Dr. Aung noted that Mr. Silvers was an "alcohol drinker" (daily) and an "active smoker" (one to two packs a day). (Id.) He also reported that at the time of the physical examination, Mr. Silvers had no other illnesses and that "[r]espiratory wise and cardiac wise he seem[ed] to be stable." (Id. at H135.)

Mr. Silvers underwent hip surgery on May 8, 2003. (Id. at H186.) Orthopedic surgeon Dr. Adishian inserted an "intramedullary hip screw" in Mr. Silvers' left hip and femur. (Id.)

Post-operation, the following day, Mr. Silvers experienced "[w]orsening shortness of breath" and was transferred to the intensive care unit ("ICU"). (Id. at H138.) Dr. Aung referred Mr. Silvers to Dr. Amjad Musthafa. (Id.) Dr. Musthafa's impressions included, among other things: (1) "[a]cute postoperative respiratory insufficiency" and "early right upper lower pneumonia" (which had "arisen within 48 hours of admission"); (2) "[a]cute exacerbation of chronic obstructive pulmonary disease"; and (3) "[c]hronic alcohol abuse with significant risk of alcohol withdrawal/delirium tremens." (Id. at H140.)

A chest x-ray taken on May 10, 2003 revealed right upper lobe pneumonia. (Id. at H161.) Another x-ray, taken the following day, revealed a "clearing of the right upper lobe infiltrate" and was "[n]egative for pneumonia." (Id. at H159.) According to the hospital discharge summary, Mr. Silvers experienced the following complications: (1) "increased hypertension," (2) "shortness of breath and confusion associated with chronic obstructive pulmonary disease," and (3) "[a]lcohol withdrawal requiring an ICU stay." (Id. at H067.) Mr. Silvers' condition continued to improve and, four days after the surgery, he was transferred out of the ICU and back to Orthopedics. (Id. at H068.) Mr. Silvers was discharged in stable condition on May 14, 2003. (Id. at ...

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