Santaella v. Metropolitan Life Ins. Co.
| Decision Date | 23 July 1997 |
| Docket Number | No. 96-2010,96-2010 |
| Citation | 123 F.3d 456 |
| Parties | 21 Employee Benefits Cas. 1552 MARY SANTAELLA and Cary Eldridge, Plaintiffs-Appellants, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant-Appellee. |
| Court | U.S. Court of Appeals — Seventh Circuit |
Mark Hellner, Chicago, IL, E. James Gildea (argued), Elmhurst, IL, for Plaintiffs-Appellants.
Paul G. Huck, Allan M. Marcus (argued), Metropolitan Life Insurance Company, Law Department, New York City, for Defendant-Appellee.
Before WOOD, JR., RIPPLE and MANION, Circuit Judges.
Appellants Mary Santaella and Cary Eldridge are the mother and husband, respectively, of Teresita Eldridge, a woman who died as the result of prescription drug intoxication; they are also the named beneficiaries in her accident insurance policy. When Metropolitan Life Insurance Company ("MetLife") neither denied nor paid their claim for accident insurance benefits, they filed suit in federal district court claiming breach of contract. The district court, considering cross-motions for summary judgment, concluded that Teresita Eldridge's death was not accidental and therefore was not covered by the group policy. It granted summary judgment to MetLife and denied it to Mary Santaella and Cary Eldridge. This appeal followed. For the reasons set forth in the following opinion, we reverse the judgment of the district court and remand the case for the entry of judgment in favor of the appellants.
The facts of this case are undisputed. Teresita Eldridge, a 36 year-old United Airlines flight attendant, was found dead in her home in Bayard, New Mexico, on July 23, 1994. The Chief Medical Investigator for the State of New Mexico, forensic pathologist Ross E. Zumwalt, M.D., performed an autopsy on her body the following day. 1 He concluded that the immediate cause of her death was "[d]rug (propoxyphene) intoxication." Certificate of Death, R.16, Ex.A. The Report of Findings and the autopsy report likewise listed the cause of death as drug intoxication of propoxyphene; they stated that the manner of death was accidental. R.16, Exs.B, C.
In his deposition, Dr. Zumwalt elaborated on his conclusions. He testified that the propoxyphene that caused Mrs. Eldridge's death was a relatively mild synthetic narcotic analgesic or painkiller often sold under the brand name Darvon. It is generally used for pain relief; however, it can cause sedation, confusion and even seizures, particularly in overdoses. The toxicology report stated that the level of propoxyphene in Teresita Eldridge's blood was 1.42 milligrams per liter. According to Dr. Zumwalt, that level was "fairly low" for a fatal dosage of propoxyphene. Although anything over one milligram per liter is considered to be within the lethal range, he testified, the average lethal blood level is 4.5 milligrams per liter, more than three times the blood level of Mrs. Eldridge at the time of her death.
Dr. Zumwalt also explained in his deposition that he had considered and ruled out the other manners of death--natural death, suicide, homicide and undetermined means--when he concluded that Teresita Eldridge's death was accidental. He noted that Mrs. Eldridge was found with a can of beer in her hand; however, the alcohol level in her system tested negative. He examined her body for evidence of natural diseases that could kill someone suddenly and unexpectedly, but found none. 2 After discussing the possibility of suicide with family members, he concluded there was no positive history of suicide attempts or ideation to suggest that cause of death. The family had informed the forensic pathologist, however, that Mrs. Eldridge had been known to take a great deal of prescription medication and to abuse drugs. Dr. Zumwalt noted that Teresita Eldridge had not taken a high toxic level of drugs on the day of her death. Nor was there evidence of undigested residual pills in the stomach, an indication of suicide found in other cases. The Medical Examiner concluded:
And so in my experience, she was the type of person who would or could have a lethal overdose of a prescription drug in an accidental manner. And finally, propoxyphene has been associated very commonly with accidental drug overdoses because there is a very small margin of safety in propoxyphene. The margin between a therapeutic dose and a toxic or lethal dose is smaller than many other drugs.... The number of pills one would have to take to get a lethal quantity is smaller in propoxyphene than in many other drugs.
R.26, Ex.2 (Zumwalt Dep.) at 21-22. 3 Consequently, with no evidence of the possibility of suicide or other manners of death, Dr. Zumwalt concluded that Mrs. Eldridge's death was accidental. In the autopsy report, Dr. Zumwalt listed two other pathologic diagnoses--splenomegaly and lymphadenopathy--which indicate an enlargement of the spleen and lymph system. Dr. Zumwalt testified that one cause for such enlargements is chronic drug use. However, these conditions were not a cause of death for Mrs. Eldridge. Dr. Zumwalt then offered his expert opinion that, within a reasonable degree of medical certainty, death was due to a propoxyphene overdose and that the manner of death was accidental.
In its Rule 12(N) Statement, MetLife added the information that on May 6, 1994, about two months before her death, Teresita Eldridge had suffered a seizure. Attached to the 12(N) Statement as an exhibit was a report of the results of a May 10, 1994, magnetic resonance imaging examination indicating that Mrs. Eldridge had "rather severe maxillary sinusitis" but no brain abnormalities. R.26, Ex.1. Also attached to the Statement as an exhibit is a barely legible page, presumably part of a medical history chart, dated May 9, 1994. Although the parties have reported what they believe portions of the handwritten notes say, neither has presented further evidence (in the form of affidavits or depositions, for example) from the medical personnel who wrote the notes or
from other doctors who had treated Mrs. Eldridge.
At the time of her death, Mrs. Eldridge was enrolled in the United Airlines' personal accident group insurance policy issued by MetLife to United Airlines. It insured Teresita Eldridge in the amount of $300,000 for accidental loss of life and dismemberment. The group policy is part of United Airline's employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974, as amended ("ERISA"), 29 U.S.C. §§ 1001 et seq. Teresita Eldridge designated as her beneficiaries under that plan her mother, Mary Santaella, and her husband, Cary Eldridge, the appellants in this case. Teresita Eldridge's premium payments were made through payroll deductions and were current.
The policy offers 24-hour protection against any accident anywhere in the world, on or off the job. It states that, if an injury results in death within one year of the date of an accident, the full benefit amount is paid. However, benefits are not paid if death results from suicide, self-inflicted injury, illness, disease, bodily infirmity or infection. The policy expressly denies coverage of "intentionally self-inflicted injuries, suicide or any attempt thereof, while sane or insane." App. at A-79. There are no definitions provided, however, for such terms as "accident," "injury" or "intentionally self-inflicted."
This case was appropriate for summary judgment resolution, stated the district court, because there are no disputed facts and because the interpretation of insurance contracts is a matter of law. The court found that the MetLife policy was not ambiguous because its undefined terms could be construed in a common-sense manner. According to the court, the reasonable interpretation of the "suicide or self-inflicted injury" exclusion of benefits is that coverage can be denied only if an insured purposefully injures herself. The reasonable interpretation of "accidental death" is one of reasonable foreseeability: "[W]ould a reasonable person with Teresita's characteristics know that serious bodily injury or death was likely to occur as a result of ingesting an overdose of propoxyphene?" R.30 at 21. The district court concluded that the answer, on this record, must be "yes." The court reasoned that Teresita Eldridge undisputedly abused drugs, as evidenced by her enlarged spleen and lymph system. The court then concluded that these conditions were most likely caused by chronic drug abuse. The court then noted that Mrs. Eldridge had suffered a seizure two months before her death and noted that seizures are a common side effect of taking an overdose of propoxyphene. Although the court acknowledged that there was no evidence that Mrs. Eldridge knew her seizure was a side effect of overdosing on propoxyphene, a reasonable person would have been alerted:
[A] reasonable person would (i) consider a seizure to be a serious physical injury, (ii) question whether the seizure was related to her drug abuse, and (iii) reasonably expect that serious injury or death was highly likely to occur if she continued to abuse drugs, including propoxyphene.
Id. The court therefore concluded that Teresita Eldridge's death was not accidental and therefore that she was not covered under the policy.
This case involves the denial of accidental death benefits claimed under an ERISA-regulated employee welfare benefit plan. In these cases, we apply the traditional de novo standard to the review of a summary judgment ruling. Casey v. Uddeholm Corp., 32 F.3d 1094, 1096 (7th Cir.1994). 4
In a summary judgment action, the moving party shoulders the initial burden of production. It must identify "those portions of 'the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any,' which it believes demonstrate the absence of a genuine issue of...
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