Biondo v. Life Ins. Co. of North America

• Decision Date: 29 September 2000
• Docket Number: No. 99-CV-74676-DT.,99-CV-74676-DT.
• Citation: 116 F.Supp.2d 872
• Parties: James BIONDO, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, a subsidiary of Cigna Corporation, Defendant.
• Court: U.S. District Court — Eastern District of Michigan

Page 872

116 F.Supp.2d 872

James BIONDO, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, a subsidiary of Cigna Corporation, Defendant.

No. 99-CV-74676-DT.

United States District Court, E.D. Michigan, Southern Division.

September 29, 2000.

Joseph T. Long, Grosse Pointe, MI, for plaintiff.

Terry J. Pawlowski, Troy, MI, for defendant.

OPINION AND ORDER DENYING PLAINTIFF'S MOTION TO REMAND AND GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT

ROSEN, District Judge.

I. INTRODUCTION

The above-captioned denial-of-benefits action is presently before the Court on two motions—Plaintiff's Motion to Remand Case Back to State Court and Defendant's Motion for Summary Judgment.¹ Opposition and reply briefs have been filed by the respective parties. Having reviewed and considered the parties briefs and supporting documents, the Court has determined that oral argument is not necessary. Therefore, pursuant to Eastern District of Michigan Local Rule 7.1(e)(2), these Motions will be decided "on the briefs." This Opinion and Order sets forth the Court's ruling.

II. PERTINENT FACTS

Plaintiff James Biondo is an general maintenance employee of University Liggett School ("Liggett") and a participant in Liggett's employee benefit plan which includes, in pertinent part, accidental dismemberment benefits covered by a group insurance policy issued by Defendant Life Insurance Company of North America ("LINA"). On April 16, 1997, Plaintiff filed a claim for accidental loss of sight benefits under the LINA group policy. [See Defendant's Summary Judgment Ex. B.] Plaintiff claimed that he suffered a retinal detachment in his right eye as the result of lifting boxes at work on September 5, 1996. Id. There was no other injury or trauma associated with Plaintiff's September 5, 1996 activities.

Mr. Biondo underwent scleral buckle surgery to repair the retinal detachment on September 6, 1996. The doctor who performed the surgery, vitreo-retinal specialist Dr. Brian Joondeph, M.D., noted prior to performing the surgery that Mr. Biondo had "Grade C2-PVR" in addition to a detached retina..² [See Dr. Joondeph's records attached at Defendant's Ex. E.] Dr. Joondeph stated in a letter dated September 10, 1996 to Dr. Gerald Mullan, Plaintiff's general opthalmologist, that due to the PVR, the prognosis was guarded. Id. Dr. Joondeph discussed his findings with Mr. Biondo and pointed out to him the risks of surgery, including the risk of progression of his PVR, and how it could lead to the need for additional surgery, including vitrectomy. Id. Mr. Biondo, nonetheless agreed to the surgery with the understanding that if his PVR progresses, the visual prognosis would be guarded. Id.

When Plaintiff presented himself to Dr. Joondeph for a post-operative examination on September 11, Dr. Joondeph observed that Mr. Biondo's retina had redetached. He stated in a September 12 letter to Dr. Mullan that this redetachment was due to PVR, reminding Dr. Mullan that Mr. Biondo had PVR present prior to his first operation. Id. As Dr. Joondeph opined, other than leaving the eye alone, the only option was further surgery. Id. Therefore, on September 20th, he performed vitrectomy surgery on Plaintiff's eye to reattach the retina. Following this second September 1996 surgery, Plaintiff was cleared to return to light duty work.

However, on October 9, 1996, Mr. Biondo's retina became detached again. He underwent additional vitrectomy surgery to his right eye for complicated retinal detachment on October 11, 1996. Plaintiff's retina was completely attached and the eye was otherwise healing nicely. This last surgery, although successful in that Plaintiff's retina remained attached, ultimately proved to be unsuccessful as Plaintiff lost essentially all vision in his right eye. Other than his monocular vision, Plaintiff has no physical limitations. He was, however, instructed to wear safety glasses at all times while at work to give an added measure of protection to his only seeing left eye.

Plaintiff's September 1996 retinal detachment was not the first problem Plaintiff had with his right eye. The records of Dr. Joondeph, in fact, establish that Plaintiff has had "a complicated ocular history." He had a traumatic cataract in his right eye and underwent cataract extraction in the 1980s. This was followed by YAG laser capsulotomy and muscle surgery. Then in July 1996, five weeks prior to the September 5 retinal detachment, Plaintiff had a secondary lens implant in that same eye. [See Dr. Joondeph's records at Defendant's Ex. E.] Records of Plaintiff's employer reveal that upon being cleared to return to work after the July 1996 lens implant surgery, Plaintiff was directed to avoid heavy lifting. [See John Hearn 9/10/96 Memo to David Boring, included within the records in Defendant's Ex. E.] Plaintiff's supervisor told him to distribute whatever packages he could—to use his judgment—and that he would arrange to have the heavier boxes handled by someone else. Id.

On April 16, 1997, Plaintiff filed a claim for accidental dismemberment "loss of sight" benefits with LINA pursuant to Liggett's Group Insurance Plan. On October 6, 1997, based on the medical records submitted by Plaintiff as well as an independent medical review of those records done by Dr. James L. Adams, M.D., an opthalmologist in Ypsilanti, Michigan, Plaintiff's claim for benefits was denied.

In her letter explaining the denial of Plaintiff's claim LINA/CIGNA Product Specialist Eleanor Mendicino stated:

Payment of proceeds are subject to various provisions described under the policy.... The provisions specific to your claim are quoted below:

The Insurance company will pay benefits for any of the losses listed below if an Employee is insured under the Policy for Accident Insurance on the date of an Accident. The loss must:

1. Be a result of bodily injuries caused directly, and from no other causes, by an Accident; and

2. Occur within 365 days of the Accident.

* * * * * *

"The Insurance Company will not pay Accident Insurance Benefits for a loss which in any way results from ... sickness, disease or bodily infirmity; medical or surgical treatment; or bacterial or viral infection, no matter how contracted. (This does not include bacterial infection that is the natural and foreseeable result of an accidental bodily injury or accidental food poisoning.)"

The following documents were submitted by the claimant for our review:

• Employers Basic Report of Injury

• Narrative note as told on 9/10/96

• Memos from Jan Manney dated 9/13/96 and 10/9/96

• Letters pertaining to Workers Compensation

• Physicians Certificate of Dr. Gerald Mullan and Dr. Brian Joondeph

• Letters from Dr., Joondeph dated 9/27/96 and 10/19/96

In addition to these documents, we have reviewed the following documentation in making our determination:

• Group/Association—Proof of Loss claim form

• Physician's Certificate completed by Julian J. Nussbaum, M.D.

• Group Policy # FLI 0050081 with University Liggett School

• Medical Records received from Julian J. Nussbaum, M.D.

• Medical Records received from Brian C. Joohdeph, M.D.

• Case file information received from Karen McCoy, Citizens Insurance

• Independent Record Review obtained through UNIVAL

The independent review revealed that you had a history of traumatic cataract in the early 80s, followed by Yag laser capsulotomy, eye muscle surgery, and secondary intraocular lens implant. This history reveals an increased risk for a retinal detachment....

Although the independent medical review contained an opinion that a retinal detachment could have occurred just as easily if you had been sitting at home in your chair rather than occurring as a result of the lifting of books, the narrative and reported accounts of the lifting of books followed closely by loss of vision does support your claim that your retinal detachment and subsequent loss of vision was caused by lifting heavy objects.

However, the independent medical review also concluded that traumatic cataract, YAG laser capsulotomy, secondary intraocular lens implant occurring prior to retinal detachment all statistically increase the risk of retinal detachment. The review further concluded that these prior events would be expected to be a significant factor contributing to the retinal detachment and current loss of vision.

In addition to the expert opinion that your prior health history would be a significant factor contributing to your retinal detachment, the records of treating physicians which we reviewed make frequent reference to your prior history of eye problems in explaining the retinal detachment in September 1996....

Since this policy, as quoted previously, does not pay Accident Insurance Benefits for a loss which in any way results from sickness, disease, or bodily infirmity, we have concluded that no benefits for accidental loss of sight are payable under the terms of [the] Policy....

Should you have any information which would prove contrary to our findings, please submit it to the undersigned. We would be pleased to review any objective information you would wish to submit.

[See Defendant's Ex. C (emphasis added).]

Ms. Mendicino's letter further advised Plaintiff of his right to request a review of the denial by writing to her within 60 days of receipt of her letter and to state the reasons why he felt the claim should not have been denied. Id. Plaintiff was further advised to include with his request for review an documentation he felt supported his claim. Id.

On December 8, 1997, Defendant received a letter from Plaintiff's attorney seeking reconsideration of the denial of Plaintiff's claim based upon what the attorney perceived to be ambiguous policy language in the general definitions of "accident" and "injury" provided at the beginning of Liggett's Group Insurance Plan brochure.³ This "appeal" was denied on January 8, 1998. [See Defendant's Ex. D.]

On August 27, 1999, Plaintiff filed a...