Kassa v. Plans Admin. Comm. of Citigroup, Inc.

• Decision Date: 30 June 2011
• Docket Number: No. CIV 10-0933 JB/ACT,CIV 10-0933 JB/ACT
• Parties: NIKKI D. KASSA, Plaintiff, v. THE PLANS ADMINISTRATION COMMITTEE OF CITIGROUP, INC. and LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendants.
• Court: U.S. District Court — District of New Mexico

NIKKI D. KASSA, Plaintiff,

v. THE PLANS ADMINISTRATION COMMITTEE OF CITIGROUP, INC.and LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendants.

No. CIV 10-0933 JB/ACT

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

Dated: June 30, 2011

MEMORANDUM OPINION AND ORDER

THIS MATTER comes before the Court on: (i) the Plaintiff's Brief in Chief, filed February 21, 2011 (Doc. 30)("Motion"); and (ii) Defendant's Response to Kassa's Brief in Chief, filed March 17, 2011 (Doc. 33)("Response"). The Court held a hearing on April 27, 2011. The primary issues before the Court are: (i) whether Defendant Life Insurance Company of North America ("CIGNA")¹ correctly determined that Richard P. Kassa's death was not a covered loss, because a pre-existing health condition, coronary artery disease -- not his accidental bodily injury, his fractured arm -- caused the death; and (ii) whether CIGNA correctly determined that an exclusion under R. Kassa's Group Accident Policy No. OK 815669 ("Group Accident Policy") barred R. Kassa's accidental dismemberment and death ("AD&D") benefits claim, because R. Kassa's coronary artery disease caused the death. The Court concludes that CIGNA improperly denied Plaintiff Nikki Kassa'sclaim, and awards N. Kassa $30,000.00, pre- and post-judgment interest, attorneys' fees, and costs.

FACTUAL BACKGROUND

This case arise out of the Defendants refusal to pay benefits related to R. Kassa's death. The facts, in summary are as follows. N. Kassa was an employee of Citigroup Inc. On September 4, 2008, N. Kassa's spouse, R. Kassa, fell in the family house and fractured his right humerus. After a one-day hospital stay, R. Kassa was discharged to return home on September 5, 2008. On September 6, 2008, R. Kassa died. The parties dispute the cause of death. N. Kassa contends that R. Kassa died from his injury; the Defendants contend that R. Kassa died from a heart condition unrelated to the injury. N. Kassa submitted an AD&D benefits claim under the Group Accident Policy, see Insurance Claim (dated September 22, 2008), filed March 14, 2011 (Doc. 32-16), which Citigroup Inc. had obtained as part of its employee group health and welfare plan ("Plan"). CIGNA denied Kassa's claim and her appeal of its denial. N. Kassa now seeks the policy amount of $30,000.00, an award of pre- and post-judgment interest, costs and attorney fees, and any other statutory or equitable relief the Court deems just and proper.

1. The Plan.

The parties agree on many of the material facts upon which N. Kassa's claims are founded. The parties agree that the Employment Retirement Income Security Act ("ERISA") governs this case. See Brief at 3; Complaint for Wrongful Denial of Accidental Death Benefits and Breach of ERISA Rights ¶ 1, at 1, filed October 1, 2010 (Doc. 1-1)("Complaint")(setting forth this fact); Amended Answer of PACC and LINA ¶ 1, at 1, filed January 14, 2011 (Doc. 22)("Amended Answer")(admitting this fact). The Plans Administration Committee of Citigroup Inc. ("PACC") is the Plan Administrator of the Group Employee Benefit Plan of Citigroup Inc. See Complaint ¶ 3, at 1-2 (setting forth this fact); Amended Answer ¶ 3, at 1 (admitting this fact). CIGNA is the ClaimsAdministrator for PACC's Accidental Death and Dismemberment and Supplemental Accidental Death and Dismemberment Insurance Benefits, and is an insurance company authorized to do business in the State of New Mexico. See Complaint ¶ 5, at 2; Amended Answer ¶ 5, at 2. CIGNA is the Claim Administrator of the Group Accident Policy and funds benefits paid under the group policy. See Complaint ¶ 6, at 2 (setting forth this fact); Amended Answer ¶ 6, at 2 (admitting this fact).

a. The Summary Plan Description.

PACC, as the Plan administrator, distributed to employees affiliated with Citigroup Inc. and its participating companies the Health and Welfare Summary Plan Description for Coverage Effective January 1, 2008, filed March 14, 2011 (Doc. 32-2 at 8)("SPD"). See Complaint ¶ 4, at 2 (setting forth this fact); Amended Answer ¶ 4, at 2 (admitting this fact). On the inside cover of the SPD, under a headline in large type stating "Important information about the contents of this document," the SPD states it "is intended to be only a summary of the major highlights of" the various benefits of the plans that makeup the Plan. The last paragraph on that same page states:

No general explanation can adequately give you all the details of the Plans. This general explanation does not change, expand, or otherwise interpret the terms of the Plans. If there is any conflict between the SPD, or any written or oral communication by any individual representing the Plans, and the Plan documents (including any related insurance contracts), the terms of the Plan documents -- including any related insurance contracts as interpreted in the sole discretion of the Plan Administrator -- will be followed in determining your rights and benefits under the Plans.

SPD at i. The SPD states that "AD&D pays a benefit if you are dismembered or die as a result of an accidental injury," SPD at 55, and that AD&D coverage is available for spouses and domestic partners, see SPD at 57. The SPD further states that AD&D benefits "are provided under insurance contracts between Citigroup Inc. and the Claims Administrator." SPD at 98. The SPD refersparticipants to "the Plan documents, which are available on the Benefits Book Online Web site" and through a toll-free telephone number. SPD at i.

b. The Group Accident Policy.

The Group Accident Policy provides the AD&D benefits available under the Plan. The Group Accident Policy states:

THIS IS AN ACCIDENT POLICY WHICH DOES NOT PAY BENEFITS FOR LOSS FROM SICKNESS.

. . . .

[CIGNA] agree[s] 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).

[CIGNA] 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.

Group Accident Policy at 1 (bold in original). The Group Accident Policy includes an exclusion that provides: "No benefits will be paid for loss resulting from . . . Sickness, disease, or bodily infirmity. (Bacterial infection resulting from an accidental cut or wound or accidental ingestion of a poisonous food substance are not excluded.)" Group Accident Policy at 3 ("Sickness Exclusion").

N. Kassa, as an employee of Citicorp Credit Services USA, an affiliate of Citigroup Inc., participated in certain employment benefits through her employment, including the Group Accident Policy between PACC and CIGNA, which provided group dependent accidental death benefits. See Complaint ¶ 9, at 3 (setting forth this fact); Amended Answer ¶ 9, at 2 (admitting this fact). At alltimes relevant to this claim, N. Kassa was enrolled in the Basic Life/AD&D Coverage with PACC, as well as the spouse supplemental AD&D coverage under the Group Accident Policy. See Complaint ¶ 10, at 3 (setting forth this fact); Amended Answer ¶ 10, at 2 (admitting this fact). R. Kassa, was insured under the Group Accident Policy at the time of his death on September 6, 2008. See Complaint ¶ 11, at 3 (setting forth this fact); Amended Answer ¶ 11, at 2 (admitting this fact). While N. Kassa was an affiliated employee, PACC provided N. Kassa a copy of the SPD. See Complaint ¶ 12, at 3 (setting forth this fact); Amended Answer ¶ 12, at 3 (admitting this fact).

2. R. Kassa's Death.

On September 4, 2008, Richard Kassa, "who was 77 years old, tripped and fell while at his home." Facsimile Transmission from ABQ Health Partners to CIGNA, re: Patient Record for Richard Kassa (dated October 28, 2008), filed March 14, 2011 (Doc. 32-18 at 21)("Medical Record"). R. Kassa suffered a comminuted fracture of the right humerus as a result of the fall and was hospitalized. See Medical Record at 3 ("X-rays revealed a comminuted fracture of the humerus."). R. Kassa was admitted to the hospital "for pain control as well as close neurovascular² monitoring." Medical Record at 3. R. Kassa's "[v]ital signs were stable on admission" to the hospital. Medical Record at 3. The Medical Record reported that R. Kassa's past medical history included Parkinson's disease, diabetes, hypertension, and high cholesterol. See Medical Record at 3. R. Kassa's "course [at the hospital] was uncomplicated." Medical Record at 4. His pain was controlled and his "neurovascular status remained stable," and on September 5, 2008, he was "deemed stable for discharge to home on the 2nd hospital day." Medical Record at 4. Dr. RichardMeredick instructed R. Kassa "to resume his normal medication routine . . . [,] to keep his coaption splint . . . clean, dry and intact at all times," and "to sleep with his head elevated at least 45 degrees." Medical Record at 4.

On September 6, 2008, N. Kassa contacted the police at 3:28 a.m. about having discovered R. Kassa "dead on a chair." State of New Mexico, Uniform Incident Report at 1 (dated September 6, 2008), filed March 14, 2011 (Doc. 32-18 at 6). See Complaint ¶ 14 at 3-4 (setting forth this fact); Amended Answer ¶ 14, at 3-4 (admitting this fact). The paramedics on the scene stated that R. Kassa "appeared to have been dead for several hours." Uniform Incident Report at 1. N. Kassa reported that R. Kassa was asleep in his chair when she had gone to bed around 10:30 p.m. See Uniform Incident Report at 1.

3. The Office of the Medical Investigator's Investigation.

The Office of the Medical Investigator ("OMI") investigated R. Kassa's death and determined that he died of complications from the accident, which aggravated his cardiovascular disease. On September 6, 2008, Medical Investigator and forensic pathologist Dr. Karen Cline-Parhamovich performed a postmortem examination of R. Kassa. See Autopsy Report (dated September 6, 2008), filed March 14, 2011 (Doc. 32-17 at 9)...