House v. Life Ins. Co. of North America

• Decision Date: 21 April 2005
• Docket Number: No. 2:04-CV-0349-RDP.,2:04-CV-0349-RDP.
• Citation: 399 F.Supp.2d 1254
• Parties: Angela M. HOUSE, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.
• Court: U.S. District Court — Northern District of Alabama

Page 1254

399 F.Supp.2d 1254

Angela M. HOUSE, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

No. 2:04-CV-0349-RDP.

United States District Court, N.D. Alabama, Southern Division.

April 21, 2005.

Calvin S. Rockefeller, III, Tuscaloosa, AL, Jeffrey N. Cotney, Gardendale, AL, for Plaintiff.

Grace C. Robinson, John David Collins, William B. Wahlheim, Jr., Maynard Cooper & Gale PC, Birmingham, AL, for Defendant.

MEMORANDUM OPINION

PROCTOR, District Judge.

I. INTRODUCTION

Pending before the court is Defendant Life Insurance Company of North America's ("LINA") Motion for Summary Judgment (Doc. # 16) filed on January 12, 2005. Plaintiff filed her Complaint on February 23, 2004, seeking insurance benefits pursuant to an accidental death policy under an Employee Retirement Income Security Act of 1974 or "ERISA"-governed plan. (Doc. # 1). In addressing Defendant's summary judgment motion, this court must determine which standard of review applies and decide whether Plaintiff is entitled to ERISA benefits. As discussed more fully below, the court finds that there are no material factual disputes and that LINA is entitled to judgment as a matter of law. Accordingly, LINA's Motion for Summary Judgment is due to be granted.

II. STANDARD OF REVIEW

Under Federal Rule of Civil Procedure 56(c), summary judgment is proper "if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). The party asking for summary judgment always bears the initial responsibility of informing the court of the basis for its motion and identifying those portions of the pleadings or filings which it believes demonstrate the absence of a genuine issue of material fact. See id. at 323, 106 S.Ct. 2548. Once the moving party has met his burden, Rule 56(e) requires the nonmoving party to go beyond the pleadings and by his own affidavits, or by the depositions, answers to interrogatories, and admissions on file, designate specific facts showing that there is a genuine issue for trial. See id. at 324, 106 S.Ct. 2548.

The substantive law will identify which facts are material and which are irrelevant. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). All reasonable doubts about the facts and all justifiable inferences are resolved in favor of the nonmovant. See Fitzpatrick v. City of Atlanta, 2 F.3d 1112, 1115 (11th Cir.1993). A dispute is genuine "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Anderson, 477 U.S. at 248, 106 S.Ct. 2505. If the evidence is merely colorable, or is not significantly probative, summary judgment may be granted. See id. at 249, 106 S.Ct. 2505.

The method used by the party moving for summary judgment to discharge its initial burden depends on whether that party bears the burden of proof on the issue at trial. See Fitzpatrick, 2 F.3d at 1115-17 (citing United States v. Four Parcels of Real Property, 941 F.2d 1428 (11th Cir.1991) (en banc)). If the moving party bears the burden of proof at trial, then it can only meet its initial burden on summary judgment by coming forward with positive evidence demonstrating the absence of a genuine issue of material fact; i.e. facts that would entitle it to a directed verdict if not controverted at trial. See Fitzpatrick, 2 F.3d at 1115. Once the moving party makes such a showing, the burden shifts to the nonmoving party to produce significant, probative evidence demonstrating a genuine issue for trial.

If the moving party does not bear the burden of proof at trial, it can satisfy its initial burden on summary judgment in either of two ways. First, the moving party may produce affirmative evidence negating a material fact, thus demonstrating that the non-moving party will be unable to prove its case at trial. Once the moving party satisfies its burden using this method, the non-moving party must respond with positive evidence sufficient to resist a motion for directed verdict at trial.

The second method by which the moving party who does not bear the burden of proof at trial can satisfy its initial burden on summary judgment is to affirmatively show the absence of evidence in the record to support a judgment for the non-moving party on the issue in question. This method requires more than a simple statement that the non-moving party cannot meet its burden at trial but does not require evidence negating the non-movant's claim; it simply requires that the movant point out to the district court that there is an absence of evidence to support the non-moving party's case. See Fitzpatrick, 2 F.3d at 1115-16. If the movant meets its initial burden by using this second method, the non-moving party may either point out to the court record evidence, overlooked or ignored by the movant, sufficient to withstand a directed verdict, or the non-moving party may come forward with additional evidence sufficient to withstand a directed verdict motion at trial based on the alleged evidentiary deficiency. However, when responding, the non-movant can no longer rest on mere allegations, but must set forth evidence of specific facts. See Lewis v. Casey, 518 U.S. 343, 358, 116 S.Ct. 2174, 135 L.Ed.2d 606 (1996) (citing Lujan v. Defenders of Wildlife, 504 U.S. 555, 561, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992)).

III. STATEMENT OF FACTS¹

LINA insured the group accidental death and dismemberment component of the Southern Company's Employee Welfare Benefit Plan (the "Plan"). (AF No. 1.1). Coverage under the policy of insurance (the "Policy") was made available to eligible employees, including Plaintiff's Decedent. (AF No. 1.2). Under the Policy, designated beneficiaries, whose claims were approved and accepted, were due to receive $300,000 in benefits. (AF No. 1.3).

The Policy contains language that states, in bold face print on the cover page, that "THIS IS A LIMITED POLICY" and further that "THIS IS AN ACCIDENT POLICY WHICH DOES NOT PAY BENEFITS FOR LOSS FROM SICNESS." (AF No. 2.1). The Policy pays benefits under the following conditions:

We agree to pay benefits for loss from bodily injuries:

a) caused by an accident which happens while an insured is covered by this policy; and

b) which, directly and from no other causes, result in a covered loss (see the Description of Coverage).

We will not pay benefits if the loss was caused by:

a) sickness, disease, or bodily infirmity; or

b) any of the Exclusions listed in the policy.

(AF No. 2.2). In addition, the exclusions section of the Policy expressly provides that: "No benefits will be paid for loss resulting from ... sickness, disease or bodily infirmity." (AF No. 2.3).

Decedent suffered from insulin-requiring type II diabetes which resulted in a multitude of health problems including retinopathy nephropathy, and gastropathy, as well as neuropathy. (AF No. 3.1). She was described by John Day, M.D. as having "advanced diabetes and multiple endorgan problems associated with it." (AF No. 3.2). Decedent's additional health problems ranged from hypertension, migraine headaches, depression, hypercholesterolemia and nephritis to gastroparesis and esophageal reflux. (AF No. 4).

Plaintiffs Decedent required hemodialysis three times a week for her end-stage kidney disease. (AF No. 5.1). As of 2000, Decedent was for all practical purposes restricted to her home given her multiple medical problems and rigorous dialysis schedule. (AF No. 5.2).

The medical records collected in connection with Plaintiffs claim further revealed that Decedent's health had been precarious for an extended period of time and that the topic of refusing life-saving measures had been previously considered. (AF No. 6.1). She had a history of going into a catatonic state in which she would be unresponsive and shaky. (AF No. 6.2). For example, Plaintiffs Decedent spent roughly ten days in the hospital in the Fall of 2000 for what was described as an "altered mental status". (AF No. 6.3). At this time, Dr. Lee documented the following:

The patient's mental status improved only slightly during the initial two-thirds of her hospital stay. It was felt her prognosis was very poor with long discussion made with her family. It was unanimous with the family members as well as the patient that patient be continued as do not resuscitate with no mechanical ventilation or advanced cardiac life support protocols.

(AF No. 6.4). In fact, Dr. Lee, Plaintiffs Decedent's treating physician, transcribed a conversation with Decedent in which "[t]he patient ... would ask that if her condition is deemed terminal that no extraordinary measures be performed to prolong her life...." (AF No. 6.5). Nasrollah Eslami, M.D., a neurologist who was consulted during this hospital stay, concluded that "given multiple medical problems ... the prognosis for recovery is poor." (AF No. 7.1). Leland Allen, M.D., an infectious disease specialist who examined Plaintiffs Decedent prior to her admission, similarly described her as being in "her usual state of fairly poor health." (AF No. 7.2).

On September 27, 2000, and again on April 25, 2001, Plaintiffs Decedent was diagnosed with renal failure. (AF No. 8.1). Dr. Tim Christopher, a surgeon, described Decedent as being in "relatively poor health" having chronic renal failure which progressed to end-stage renal disease. (AF No. 8.2). Plaintiffs Decedent's renal deterioration required her to undergo a series of procedures to create a permanent hemodialysis access site on her arm. (AF No. 9.1). The first port site proved unworkable as Plaintiffs Decedent experienced diminished activity and no flow in the graft. (AF No. 9.2). Therefore, Dr. Christopher performed another procedure and created an upper...