Miller v. Hartford Life Ins. Co.

• Citation: 348 F.Supp.2d 815
• Decision Date: 06 December 2004
• Docket Number: No. CIV.03-40056.,CIV.03-40056.
• Parties: Earl D. MILLER, Plaintiff, v. THE HARTFORD LIFE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Eastern District of Michigan

Page 815

348 F.Supp.2d 815

Earl D. MILLER, Plaintiff, v. THE HARTFORD LIFE INSURANCE COMPANY, Defendant.

No. CIV.03-40056.

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

December 6, 2004.

Carol A. Kuhnke, Davis & Kuhnke, Peter A. Davis, Davis & Kuhnke, Ann Arbor, MI, for Earl D. Miller, Plaintiff.

Michael A. Alaimo, Michael A. Alaimo, Miller, Canfield, (Detroit), Detroit, Michael A. Alaimo, Dickinson Wright, Bloomfield Hills, MI, for Hartford Life Insurance Company, Defendant.

ORDER GRANTING DEFENDANT'S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE RECORD

GADOLA, District Judge.

I. Introduction

Before the Court are the parties' cross-motions for judgment on the administrative record. Because the Court concludes that Plaintiff is not entitled to benefits under an insurance contract, the Court will grant Defendant's motion and deny Plaintiff's motion.

II. Statement of Facts

Plaintiff, the husband of Barbara Miller, had an accidental death and dismemberment policy with defendant Hartford Life Insurance Company ("Hartford"). Under the policy, Hartford agreed to pay benefits if an injury within the terms of the policy occurred. Plaintiff and his wife were covered under this policy. This case concerns whether Plaintiff may recover under the policy for his wife's death due to complications from surgery.

On January 2, 1997, Mrs. Miller had her gallbladder removed. Almost two years later, on December 15, 1998, doctors found a remaining gallstone. The doctor thought that the stone was "perhaps in her cystic duct remnant." (Administrative Record ("A.R.") at 54). Doctors performed an endoscopic retrograde cholangiopancreatography ("ERCP") on Mrs. Miller on December 18, 1998 to remove the gallstone. The gallstone was not removed, and doctors ceased working due to Mrs. Miller's agitation. Mrs. Miller died the next day, December 19, 1998.

The administrative record details the causes of Mrs. Miller's death. According to the certificate of death, amended on May 16, 2001, the immediate cause of death was peritonitis. The underlying cause was acute pancreatitis. As a "significant condition[ ] contributing to death but not resulting in the underlying cause [i.e. acute pancreatitis]," the certificate listed, "Status Post [ERCP] and Complications." (A.R. at 134). The medical examiner classified the cause of death as an "accident." (A.R. at 134). Under the section entitled "Describe How Injury Occurred," he wrote, "Inadvertent injury of the biliary tree during ERCP." (A.R. at 134).

In the autopsy protocol, amended on May 16, 2001, the cause of death is listed as "Peritonitis due to Acute Pancreatitis due to Cholelithiasis." The contributory cause is listed as "Status Post [ERCP] and Complications." (A.R. at 36). In the "Internal Examination" section, under "Body Cavities," the investigator wrote, "There is an accumulation of purulent material in the abdominal cavity." (A.R. at 38). Under "Liver and Biliary System," he wrote, "There is a 1 cm in diameter yellow multi-shaped stone in the main bile duct." (A.R. at 39).

After his wife's death, plaintiff filed a "Proof of Loss-Accidental Death" form with Hartford on August 6, 2001. Hartford denied this claim in a letter dated February 4, 2002. Hartford based its denial on the "medical or surgical treatment" exclusion of the policy. (A.R. at 29-32). Plaintiff appealed this decision with Hartford in a letter dated March 15, 2002. (A.R. at 22). Hartford denied this appeal on May 17, 2002. Hartford asserted that Mrs. Miller died from pancreatitis, a sickness or disease under the policy, and not from complications of the surgery. Hartford also asserted that if plaintiff died from complications of the surgery, recovery would be denied under the medical or surgical treatment exclusion. (A.R. at 12-13).

Plaintiff subsequently filed this complaint in the Wayne County Circuit Court of Michigan. Defendant removed the action to this Court on March 7, 2003, under diversity and federal question jurisdiction. This is a denial of benefits claim under the Employee Retirement Income Security Act ("ERISA"). 29 U.S.C. § 1132(a)(1)(B) (2004). Both plaintiff and defendant have filed motions for judgment on the administrative record.

III. Standard of Review

The Court reviews ERISA denial of benefits claims "under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). The de novo standard "applies to the factual determinations as well as to the legal conclusions of the plan administrator." Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 613 (6th Cir.1998). When undertaking a de novo review, the Court "simply decides whether or not it agrees with the decision under review." Anderson v. Great W. Life Assurance, 777 F.Supp. 1374, 1376 (E.D.Mich.1991) (Gadola, J.) (quoting Perry v. Simplicity Eng'g, 900 F.2d 963, 966 (6th Cir.1990)). "The administrator's decision is accorded no deference or presumption of correctness." Hoover v. Provident Life & Accident Ins. Co., 290 F.3d 801, 809 (6th Cir.2002). The court's role is to "determine whether the administrator properly interpreted the plan and whether the insured was entitled to benefits under the plan." Id. In this case, the Court finds no language in the Hartford's policy granting discretionary authority to Hartford. Therefore, the Court reviews the finding of the plan administrator under the de novo standard. Defendant does not dispute the application of the de novo standard.

To interpret ERISA claims, the Court "appl[ies] `general rules' of contract law as part of the federal common law.... The federal common law may draw on state law principles, but state law is not controlling authority." Cassidy v. Akzo Nobel Salt, Inc., 308 F.3d 613, 615 (6th Cir.2002). The terms of an ERISA policy should be examined "according to their plain meaning, in an ordinary and popular sense." Marquette Gen. Hosp. v. Goodman Forest Indus., 315 F.3d 629, 633 (6th Cir.2003). "In applying this `plain meaning analysis,' the court `must give effect to the unambiguous terms of an ERISA plan.'" Cassidy, 308 F.3d at 618 (quoting Lake v. Metro. Life Ins. Co., 73 F.3d 1372, 1379 (6th Cir.1996)).

IV. Analysis

A. Whether the Harm Complained of Qualifies as an "Accident" Under the Hartford Policy

Plaintiff's Hartford policy defines "injury" as follows:

Injury means bodily injury resulting directly from accident and independently of all other causes which occurs while the Covered Person is covered under this policy. Loss resulting from:

a) sickness or disease, except a pus-forming infection which occurs through an accidental wound; or

b) medical or surgical treatment of a sickness or disease is not considered as resulting from injury.

(The Hartford Policy at 150) (emphasis added). The Court must therefore consider two aspects of the policy: (1) whether the injury to Mrs. Miller is an "accident" and (2) whether to apply either the "sickness or disease" exclusion or the "medical or surgical treatment of a sickness or disease" exclusion.

The Court first considers whether Mrs. Miller's injury is an "accident." Plaintiff alleges that negligence by the doctors during his wife's operation resulted in her death. Plaintiff thus claims that the medical malpractice of his wife's doctors constitutes an "accident" under the terms of the policy. When interpreting exclusionary language in a policy similar to the language here, courts routinely hold that medical malpractice is not an accident. For example, in an unpublished opinion, the Court of Appeals for the Sixth Circuit held that medical malpractice was not an accident. Swisher-Sherman v. Provident Life & Ins. Co., No. 93-3959, 1994 WL 562050, 1994 U.S.App. LEXIS 28768, at *8 (6th Cir. Oct. 13, 1994). In Swisher-Sherman, an insured man received a prescription for heart medication. The pharmacist gave him the wrong drug, and the man died. His wife sought benefits from the defendant insurance company, claiming that her husband's death was an "accident." The insurance company decided that the man's death was excluded from coverage under language which read, "[N]o benefits shall be paid if [the insured's] loss directly or indirectly results from:... disease of any kind, or medical or surgical treatment for any such infirmity or disease." Id. at *2-3. The court held that the clear and unambiguous meaning of the contract indicated that policy did not cover this particular incident, since the drugs were given to the man as part of his medical treatment. The court stated, "[e]very act of medical malpractice is to some extent an accident, if one equates `accident' with `unintended,' because it is outside the course of the intended medical treatment.... [S]uch medical mishaps can only occur during the course of treatment; and that's all the exclusionary provision here cares about." Id. at *5-6. Therefore, the court held that an accidental death and dismemberment policy did not cover loss from medical malpractice. The facts in Swisher-Sherman are analogous to those in the present case, in which Plaintiff contends that his accidental death and dismemberment policy covered his wife's death from alleged medical malpractice.

Similarly, a court in this district has held that an accidental death benefit policy did not cover an injury caused by poor medical treatment. Pickard v. Transamerica Occidental Life Ins. Co., 663 F.Supp. 126, 127 (E.D.Mich.1987) (Woods, J.). In Pickard, a man visited the hospital for treatment of ulcerative colitis. To prepare for a colonoscopy, he drank a solution; however, he was given the wrong solution, and died. The man's insurance policy excluded coverage "if the individual's loss shall directly or wholly result from: ... (c) bodily or mental infirmity, disease of any kind,...