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Cheryl Williams, A California Citizen v. National Union Fire Insurance Co of Pittsburgh

April 9, 2013

CHERYL WILLIAMS, A CALIFORNIA CITIZEN, PLAINTIFF,
v.
NATIONAL UNION FIRE INSURANCE CO OF PITTSBURGH, PA, A PENNSYLVANIA CORPORATION, DEFENDANT.



The opinion of the court was delivered by: Hon. Anthony J. Battaglia U.S. District Judge

ORDER DENYING PLAINTIFF'S CROSS-MOTION FOR SUMMARY JUDGMENT AND GRANTING DEFENDANT'S CROSS-MOTION FOR SUMMARY JUDGMENT [Doc. Nos. 21, 22 ]

Presently before the Court are the cross-motions for summary judgment filed by Plaintiff Cheryl Williams ("Plaintiff") (Doc. No. 21) and Defendant National Union Fire Insurance Co. of Pittsburgh, PA ("Defendant"), (Doc. No. 22).*fn1 The hearing set for April 18, 2013 is hereby vacated as the Court finds these motions appropriate for submission on the papers without oral argument pursuant to Civil Local Rule 7.1.d.1. For the reasons set forth below, Plaintiff's cross-motion for summary judgment is DENIED, and Defendant's cross-motion for summary judgment is GRANTED.

BACKGROUND

Factual History

This case arises out of the denial of a claim for accidental death benefits under a Blanket Accident Insurance Policy ("Policy") issued to Paul Ecke Ranch, Inc. ("Paul Ecke Ranch") by Defendant. Defendant issued an insurance policy, number GTP 9116405, which provided accidental death benefits to Paul Ecke Ranch employees from February 15, 2010, to February 15, 2011. (Administrative Record ("A.R.") 00037.)*fn2

Plaintiff's husband, Jack Williams ("Mr. Williams"), was employed by Paul Ecke Ranch, and insured by the Policy issued by Defendant. (A.R. 00039.) Under the Policy, Mr. Williams was eligible to receive an "Accidental Death Benefit" of one million dollars; Plaintiff was designated as the beneficiary under the Policy. (A.R. 00038, 00050.) The Policy's general insuring clause provides, "If injury to the Insured Person results in death within 365 days of the date of the accident that caused the Injury, the Company will pay 100% of the Principle Sum." *fn3 (A.R. 00009.)

At the time of Mr. Williams' death, he was the international products manufacturer and technical support representative for Paul Ecke Ranch in Encinitas, California. (A.R. 00614.) Mr. Williams traveled extensively for his job, including international trips to Japan and Australia. (A.R. 00200.) Immediately prior to his death, Mr. Williams spent approximately twenty-eight hours in flight over a five-day period. (A.R. 00200.) During this time, Mr. Williams traveled from the United States to Japan and then to Australia. (A.R. 00200.) On August 18, 2010, Mr. Williams was preparing to travel to Melbourne, Australia, when he collapsed outside of his hotel in Terrigal, Australia. (A.R. 00200.)

Mr. Williams was taken to a local hospital where he was pronounced dead upon arrival. (A.R. 00200.) An autopsy was performed by the Newcastle Department of Forensic Medicine, the details of which are included in an Autopsy Report ("Report"), dated June 9, 2011. (A.R. 00200.) The Coroner determined Mr. Williams died of a massive Pulmonary Thromboembolism ("PE"), with an "antecedent" cause of Deep Vein Thrombosis ("DVT"). (A.R. 00200.) Additionally, the Coroner noted that "migration of emboli from the leg veins had occurred over a period of a few days," and there was a possibility "that the onset of formation of [the] thromboemboli may have occurred around the same time of [Mr. Williams'] air travel." (A.R. 00201.) Mr. Williams' autopsy did not reveal any sign of external trauma, (A.R. 00199 - 00209), and neither party references any unusual occurrences on the flights preceding Mr. Williams' death.

Terms Of The Policy

Under the Policy, Defendant agreed to "insure eligible persons . . . against loss covered by this Policy subject to its provisions, limitations, and exclusions." (A.R. 00144.) Relevant portions of the Policy provide coverage related to travel on a Civilian Aircraft, specifically extending coverage for "[i]njury sustained while riding as a Passenger in or on (including getting in or out of, or on or off of): any Civilian Aircraft . . .." (A.R. 00159.) "Injury" is specifically defined by an endorsement to the policy as follows:

Injury- means bodily injury: (1) which is sustained as a direct result of an unintended, unanticipated accident that is external to the body and that occurs while the injured person's coverage under this Policy is in force; (2) which occurs under the circumstances described in a Hazard applicable to that person; and (3) which directly (independent of sickness, disease, mental capacity, bodily infirmity or any other cause) causes a covered loss under a Benefit applicable to such Hazard. (A.R. 00173.) The Policy also sets forth several exclusions to coverage, including bodily injury that results from "sickness, disease, mental incapacity or bodily infirmity" or "stroke or cerebrovascular accident or event; cardiovascular accident or event; myocar-dial infarction or heart attack; coronary thrombosis; aneurysm." (A.R. 00173 - 00174.) The applicable terms of the Policy, including the above-mentioned endorsement and exclusions, will be discussed further below.

Plaintiff's Claim For Benefits Under The Policy

On October 29, 2010, Plaintiff submitted a "Proof of Loss - Accidental Death" claim form to Defendant. (A.R. 00050 - 00051.) On November 4, 2010, Defendant, through its claims administrator Chartis Claims, Inc. ("Chartis"), sent a letter to Plaintiff acknowledging receipt of her claim for accidental death benefits. (A.R. 00052) The letter explained Defendant was reviewing Plaintiff's claim, and confirmed the Policy "provide[d] benefits when an eligible person sustains a bodily injury caused by an accident resulting directly and independently of all other causes." (A.R. 00052.) Defendant sent Plaintiff an additional letter on February 3, 2011, indicating that it was investigating the claim and in the process of obtaining information concerning Mr. Williams' death, including Mr. Williams' death certificate, business travel itinerary, and any police or hotel security reports. (A.R. 00070.) On February 28, 2011, Defendant sent Plaintiff a letter detailing the process of the investigation and status of the requested documents. (A.R. 00084.)

Plaintiff responded to Defendant via email on March 7, 2011, providing Defendant with Mr. Williams' travel itinerary for the day he died. (A.R. 00088 - 00090.) Plaintiff also provided Defendant with information regarding a previous Workers' Compensation claim for Mr. Williams' which had been approved. (A.R. 00088 - 00090.) Plaintiff explained that Mr. Williams was given a "clean bill of health" approximately three months before his death, and that the medical report indicating as such was included in the Workers' Compensation approval. (A.R. 00090.) On March 18, 2011, Defendant received a confidential Investigative Report from International Claims Specialist, a third-party investigative service. (A.R. 00119 - 00136.) The Investigative Report included a letter from the Gosford Coroners Court, a copy of Mr. Williams' death certificate, and a letter from Hortica Insurance & Employee Benefits regarding Mr. Williams' Workers' Compensation benefits and claim. (A.R. 00118 - 00136.) The letter from the Gosford Coroners Court indicated Mr. Williams' cause of death was PE and DVT. (A.R. 00127.)

On July 18, 2011, Defendant sent a letter to Plaintiff informing her that the claim file had been sent to management for a final claim determination. (A.R. 00236.) In August 2011, Plaintiff forwarded Defendant a copy of the Stipulation with Request for Award in the Workers' Compensation Appeal Board matter involving Mr. Williams' death. (A.R. 00252 - 00254.) The Stipulation awarded benefits to Mr. Williams' daughter and partial dependent, Bethany Williams. (A.R. 00252 - 00254.)

On September 1, 2011, Defendant denied Plaintiff's claim for benefits under the Policy. (A.R. 00624 - 00625.) Specifically, the denial letter provided as follows: "[I]t is our position the record does not demonstrate that Mr. Williams' death resulted from a bodily injury sustained as a direct result of an unintended, unanticipated accident that was external to the body, but that his death occurred due to a sickness, which likely developed over a period of days and was not caused by an unintended, unforeseen, or unexpected event." (A.R. 00642 - 00645.) Additionally, the denial letter concluded the "policy specifically excludes coverage for losses that result, in whole or in part from sickness, disease, mental incapacity or bodily infirmity where the loss results directly or indirectly from any of these." (A.R. 00257.) The letter also informed Plaintiff of her right to appeal Defendant's decision, and encouraged Plaintiff to submit any additional documentation to support her claim for benefits under the Policy. (A.R. 00414 - 00416.) Plaintiff subsequently submitted additional information regarding Mr. Williams' flight history immediately preceding his death. (A.R. 00323.) Additionally, Plaintiff filed a timely appeal of Defendant's determination on December 1, 2011. (A.R. 00277.)

In February 2012, Defendant obtained outside legal counsel to review the appeal filed by Plaintiff along with the original denial of Plaintiff's claim.*fn4 (A.R. 00339, 00350.) Defendant's outside counsel determined that Mr. Williams' death did not result from an "accident" within the terms of the Policy. (A.R. 00350.) This conclusion was detailed in a letter from outside counsel to Chartis dated February 26, 2012, which included an analysis of the Policy, the claims file, and applicable case law. (A.R. 00350 -00369.) On March 6, 2012, Defendant informed Plaintiff the file was scheduled for review by the Employee Retirement Income Security Act ("ERISA") Appeal Committee. (A.R. 00869 - 00871.) The Administrative Record, including the opinion letter from Defendant's outside counsel, was submitted to the ERISA Appeal Committee for review on April 18, 2012. (A.R. 00869 - 00871.) On April 25, 2012, Plaintiff was advised the ERISA Appeal Committee denied Plaintiff's claim based upon its determination that Mr. Williams' death was not the result of bodily injury sustained as a direct result of an unintended, unanticipated accident that was external to the body. (AR 00870, 00872 -00873.)

Procedural History

Plaintiff thereafter filed a Complaint against Defendant in this Court alleging a violation of Section 502(a)(1)(B) of ERISA, 29 U.S.C. Ch. 18, which provides certain rights and remedies for individuals who participate in employee benefits plans. (Doc. No. 1.) Specifically, Section 502(a)(1)(B) permits a beneficiary of an employee benefit plan to bring a civil action to recover benefits owed under the terms of the plan. The parties jointly filed the Administrative Record on November 16, 2012. (Doc. No. 14-1.) Pursuant to the briefing schedule set by the Court, each party filed their respective motions for summary judgment on December 18, 2012. (Doc. Nos. 21, 22.) The parties filed their ...


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