Garza v. Sun Life Assurance Co. of Canada

• Decision Date: 29 April 2013
• Docket Number: CIVIL ACTION NO. 7:12-CV-188
• Parties: CYNTHIA GETNER GARZA, Plaintiff, v. SUN LIFE ASSURANCE COMPANY OF CANADA, Defendant.
• Court: U.S. District Court — Southern District of Texas

CYNTHIA GETNER GARZA, Plaintiff,

v.SUN LIFE ASSURANCE COMPANY OF CANADA, Defendant.

CIVIL ACTION NO. 7:12-CV-188

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF TEXAS MCALLEN DIVISION

SO ORDERED: April 29, 2013

ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT

AND GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT

I. Factual Background

Now before the Court are Plaintiff Cynthia Getner Garza's Motion for Summary Judgment (Doc. 23) and Defendant Sun Life Assurance Company of Canada's Motion for Summary Judgment (Doc. 24). Plaintiff brings this action pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA") to recover accidental death benefits under a group insurance policy issued by Defendant Sun Life to the employer of Plaintiff's deceased husband, Raul Garza, Jr. (Doc. 21); see 29 U.S.C. § 1132(a)(1)(B) (authorizing beneficiary to bring federal civil action to recover benefits due under ERISA plan). The insured, Mr. Garza, was allergic to wasp venom and died on October 16, 2011 shortly after being stung by a wasp. Sun Life paid life insurance benefits to Plaintiff under the policy but denied her claim for accidental death benefits, determining that Mr. Garza's death was excluded from coverage because it constituted a "loss which is due to or results from:...bodily...infirmity or disease." Through their Cross-Motions for Summary Judgment, the parties seek the Court's resolution of their coverage dispute. Upon review of the Cross-Motions, responsive briefing, and summary judgmentevidence, in light of the relevant law, the Court finds that Plaintiff's Motion must be denied and that Defendant's Motion must be granted, for the following reasons. See (Docs. 23, 24, 26, 27, 29).

II. Overview of Summary Judgment Standard of Review in ERISA Case

A district court must grant summary judgment when there is no genuine dispute as to any material fact and the moving party is entitled to judgment as a matter of law. FED. R. CIV. P. 56(a). District courts within this Circuit have described the summary judgment standard of review in ERISA cases as "unique," in that the court acts in an appellate capacity reviewing the decisions of the ERISA plan administrator. E.g., McFadden v. Prudential Ins. Co. of Am., 877 F.Supp.2d 481, 485 (S.D.Miss. 2012). As a general rule, the court is "limited to the administrative record and may inquire only whether the record adequately supports the administrator's decision." Jenkins v. Cleco Power, LLC, 487 F.3d 309, 314 (5th Cir. 2007) (quoting Gooden v. Provident Life & Accident Ins. Co., 250 F.3d 329, 333 (5th Cir. 2001)) (internal quotations omitted); see also Estate of Bratton v. Nat'l Union Fire Ins. Co., 215 F.3d 516, 521 (5th Cir. 2000).

The plan administrator makes two general determinations when deciding a claimant's entitlement to benefits: "(1) finding the facts underlying the claim and (2) determining 'whether those facts constitute a claim to be honored under the terms of the plan.'" Firman v. Life Ins. Co. of N. Am., 684 F.3d 533, 538 (5th Cir. 2012) (quoting Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 394 (5th Cir. 1998)) (emphasis in original). Courts always review the administrator's fact findings for abuse of discretion. Id. at 538. The administrator's interpretation of the plan "is typically reviewed de novo, '[b]ut where...a plan expressly confers discretion on the plan administrator to construe the plan's terms, the administrator's construction is reviewed for abuseof discretion." Id. (quoting Wade v. Hewlett-Packard Dev. Co. LP Short Term Disability Plan, 493 F.3d 533, 537-38 (5th Cir. 2007)); see also Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).

III. Summary Judgment Evidence

A. The Policy

At the time of his death, Mr. Garza was employed as the Facilities Director for Laredo Medical Center and was insured under Policy Number 10471-001 (the "Policy") issued by Sun Life to CHS/Community Health Systems, Inc. (Doc. 23, Ex. 1; AR at 1).¹ Mr. Garza designated Plaintiff as the sole beneficiary under the Policy. (AR at 8). The "Accidental Death and Dismemberment Insurance" provisions of the Policy state that "[i]f Sun Life receives Notice and Proof of Claim that an Insured Person.sustains an Accidental Bodily Injury while insured, which results in loss of life,...Sun Life will pay [benefits], subject to the Exclusions...." (AR at 431). The Policy defines "Accidental Bodily Injury" as "bodily harm caused by an accident which is sustained directly and independently of all other causes." (AR at 418). The "Exclusions" provide that "no Accidental Death...payment will be made for a loss which is due to or results from:...bodily or mental infirmity or disease of any kind, or infection unless due to an accidental cut or wound." (AR at 436).

B. Mr. Garza's Death

On October 16, 2011 at approximately 12:30 pm, Mr. Garza was driving his motorcycle on Texas Highway 100 when he pulled over to the side of the highway. (AR at 201, 133-34). Plaintiff had been following in her truck and also pulled over to check on her husband. Id. Mr. Garza told Plaintiff that he had been stung on the left leg by a wasp. (AR at 201). Both were aware that Mr. Garza was allergic to wasp venom. (AR at 205, 272). Either Mr. Garza orPlaintiff administered an "EpiPen" to Mr. Garza to counter the effects of the wasp sting. (AR at 134, 201, 272). Mr. Garza began to have trouble breathing and became increasingly unresponsive. (AR at 201). Plaintiff called 9-1-1 and began to administer cardio-pulmonary resuscitation ("CPR") until Emergency Medical Services ("EMS") arrived. Id.

The EMS report notes that Mr. Garza went into full cardiac arrest and lists the "suspected illness" as "allergic reaction" and "bee sting." (AR at 135). EMS personnel injected several doses of epinephrine, the medication also contained in the EpiPen, to counteract the allergic reaction. (AR at 136). EMS transported Mr. Garza to Valley Regional Medical Center where he was pronounced dead at 1:48 pm after life-saving measures were unsuccessful. (AR at 4, 133-34, 201).

Mr. Garza's autopsy report and death certificate both state that he had a "history of hymenoptera allergy" (i.e., allergy to the venom of insects belonging to the order hymenoptera, including wasps),² and that the cause of his death was "anaphylaxis due to hymenoptera envenomation." (Doc. 23, Ex. B; AR at 4, 146). The autopsy showed that Mr. Garza's blood contained a moderate level of paper wasp venom. (AR at 146, 151).

C. Denial of Plaintiff's Claim and Appeal

In November 2011, Plaintiff filed a claim with Sun Life to recover life insurance and accidental death (hereinafter "AD") benefits under Mr. Garza's Policy. (AR at 1-2). In December 2011, Sun Life paid life insurance proceeds to Plaintiff and notified her that it would be requesting and reviewing "all police or governmental investigation or other accidental reports and any toxicology or laboratory reports" prior to rendering a decision on her AD claim. (AR at 27, 31). Sun Life assigned the AD claim to Senior Benefits Consultant John Baptista, who hired third-party investigator Claims Bureau USA, Inc. to obtain copies of the police, EMS, autopsy,and toxicology reports. (AR at 121, 186, 220, 349). Mr. Baptista reviewed this information in determining whether Mr. Garza's death was covered under the AD provisions of the Policy. See (Doc. 23, Ex. C; AR at 123-25). In a letter dated February 13, 2012, Mr. Baptista informed Plaintiff of Sun Life's denial of her AD claim on two grounds. Id. First, Mr. Garza's death was not "caused by an accident which is sustained directly and independently of all other causes," in that his hymenoptera allergy "was a known, pre-existing condition that made him susceptible to the reaction he sustained following the wasp sting." (AR at 124). Second, even if an accident, Mr. Garza's death was excluded from coverage because his allergy was a "bodily infirmity or disease." Id. In support of the latter finding, Mr. Baptista cited to a page of a publication by the U.S. Department of Health and Human Services ("HHS"), National Institute of Allergy and Infectious Diseases, entitled "Understanding the Immune System: How It Works." Id. That page contains the following paragraph under the heading "Disorders of the Immune System":

Allergic Diseases

The most common types of allergic diseases occur when the immune system responds to a false alarm. In an allergic person, a normally harmless material such as grass pollen or house dust is mistaken for a threat and attacked.

(Doc. 23, Ex. F; AR at 76). Mr. Baptista explained that "Mr. Garza died from anaphylaxis, which was due to or resulted from his allergy. If his allergy were not present, the wasp sting would not have resulted in his death." (AR at 124).

In April 2012, represented by counsel, Plaintiff appealed Sun Life's decision on two bases. (Doc. 23, Ex. D; AR at 108). First, Plaintiff took the position that Mr. Garza died not because of a pre-existing allergy but "because the EpiPen injection he administered to himself failed." Id. Second, Plaintiff pointed to the fact that another insurer had paid accidental death benefits to Plaintiff "when it had the same benefit data [Sun Life] had." Id. Plaintiff enclosed copies of correspondence verifying such payment, but not copies of the underlying decision orpolicy. See (AR at 110-12).

By letter dated June 6, 2012, Sun Life Benefits Consultant Morse W. Doane upheld Sun Life's denial of Plaintiff's AD claim. (Doc. 23, Ex. E; AR at 36-39). Mr. Doane rejected Sun Life's first basis for its original denial, clarifying that the test was not whether Mr. Garza's death was "caused by an accident which is sustained directly and independently all other causes," but whether Mr. Garza sustained an "Accidental Bodily Injury" resulting in loss of life. (AR at 36-37). Mr. Doane reasoned that Mr. Garza did sustain an "Accidental Bodily Injury" as defined by the Policy because he "experienced 'bodily harm'...