Appellate Court Agrees with Zurich Decision to Deny Accidental Death Benefits to Wife of Man with Cardiac Condition
On May 22, 2014, at about 9:30 a.m., Joseph Arruda was traveling on a four-lane highway in Hadley, Massachusetts when his car suddenly crossed all lanes of traffic, hit an oncoming car, then hit the curb, rolled over, and landed with its wheels on the ground on the opposite side of the road than the one in which he was originally traveling. He was alive when reached by first responders but died moments later and was pronounced dead at the scene.
Mr. Arruda was covered for accidental death or injury under his employer’s Basic Accident Policy issued by Zurich American Insurance Company (Zurich) with his wife as the named beneficiary. The Terms of the Policy were that Zurich would pay benefits if the loss of life was due to a covered injury. A “covered injury” was defined as “an Injury directly caused by accidental means which is independent of all other causes.”
The policy also gave Zurich the “discretionary authority to determine eligibility for benefits and to construe the terms of the plan.” When Mrs. Arruda filed a claim for the accidental death benefits, Zurich hired CS Claims Group, Inc. (CS Group) to gather all medical records and investigate the claim.
Ultimately, Zurich denied Mrs. Arruda’s claim on the grounds that Mr. Arruda’s car crash and ultimate death were due to his pre-existing cardiac disease. She filed an administrative appeal. Zurich upheld its denial and Mrs. Arruda filed an ERISA lawsuit in the United States District Court for the District of Massachusetts.
The District Court found in favor of Mrs. Arruda and held that Zurich wrongfully denied her death benefits and that Zurich’s denial was arbitrary and capricious and not supported by substantial evidence. Zurich appealed that decision to the United States Court of Appeals for the First Circuit.
In Denise Arruda v. Zurich American Insurance Company, the Appeals Court (Court) agreed with Zurich and reversed the opinion of the District Court. The Court held that “Zurich’s decision to deny the claim was supported by substantial evidence.”
The Court analyzed carefully all the evidence relied upon by Zurich in denying the claim, including Mr. Arruda’s medical history, official reports of the accident, autopsy reports and death certificates, and medical expert opinions submitted by both Zurich and Mrs. Arruda. The Court found the evidence denying Mrs. Arruda’s claim was substantial and upheld Zurich’s decision.
Evidence Relied Upon by Zurich in Denying Mrs. Arruda’s Claim for Death Benefits
Mr. Arruda’s medical records:
He suffered from 27 separate medical conditions from 2004 until his death. Most relevant to the cause of death were the diagnoses of arrhythmias and heart failure.
Four months prior to the accident, he had a surgical procedure that implanted an implantable cardioverter defibrillator (ICD) that monitored his heart rate and rhythm and administered electrical shocks to restore normal heart rhythm when necessary. The ICD was manufactured by Boston Scientific that kept a running logbook about when the device administered electrical shocks.
Autopsy findings, death certificates, and other reports:
A report from the first responders issued the same day as the accident listed impressions as “Primary: Cardiac Arrest” and “Secondary: Motor Vehicle Accident”.
On June 9, 2014, the town of Hadley, Massachusetts issued a death certificate that listed the primary cause of death as “hypertensive heart disease.”
On June 12, 2014, Dr. Andrew Sexton of the Commonwealth of Massachusetts’ Office of the Chief Medical Examiner issued an autopsy report showing “Cause of Death: Hypertensive heart disease.” “Contributing Factors: Cervical Spine Fracture due to Blunt Force Trauma.” During the autopsy, the ICD was removed and sent to Boston Scientific for an analysis.
On August 25, 2014, the Massachusetts State Police completed an “ACISS Homicide/Death Report.” Based on interviews with witnesses concerning the trajectory of the crash and fact that Mr. Arrudawas briefly alive after the accident, the police concluded that “Mr. Arruda experienced some type of medical episode while driving his vehicle.”
On February 18, 2015, the Massachusetts State Police also completed a collision analysis and accident reconstruction report which ruled out all possible causes of the accident and concluded, “Mr. Arruda had suffered a catastrophic medical event which caused him to be unable to control his vehicle.”
Zurich had all the available information, including Arruda’s medical records, turned over to medical doctors for review. All concluded that the crash was caused by Mr. Arruda’s heart disease. Zurich therefore denied Mrs. Arruda’s claim for death benefits.
Evidence Presented by Mrs. Arruda on Administrative Appeal of the Denial of Her Claim
Mrs. Arruda’s primary evidence to support her claim that the cause of death was the traumatic injury suffered by Mr. Arruda in the car crash was the ICD logbook provided by Boston Scientific. Significant was an entry 75 minutes before Mr. Arruda’s death “for a successful rhythm ID update.”
The logbook contained no record of the cessation of Mr. Arruda’s heartbeat even though it continued recording for four-and-a-half hours after Mr. Arruda was pronounced dead. Mrs. Arruda never submitted any information about how to interpret the logbook.
Mrs. Arruda also submitted the report of Dr. Laposata, a physician employed by the Forensic Pathology & Legal Medicine, Inc., located in Providence, Rhode Island. The doctor was the former Chief Medical Examiner for Rhode Island. She concluded that the death was due to the blunt force trauma of the accident but noted that: “The exact reason Mr. Arruda traveled across several traffic lanes and into the other vehicle is unclear.” The expert expressed no opinion whether his preexisting medical conditions caused or contributed to the accident.
Review of Mrs. Arruda’s Administrative Appeal Evidence
Zurich hired a medical expert to review the new evidence submitted by Mrs. Arruda including the expert’s opinion and Boston Scientific’s logbook. He agreed that the accident was caused by “several possible pre-existing illnesses or diseases, singly or in combination…”.
Mrs. Arruda submitted another report by Dr. Laposata whose comment was somewhat conclusionary stating that she stood by her original opinion.
Appeals Court Agrees with Zurich
The Court noted that descriptions in the record were consistent in their conclusions that the accident was caused, at least in part, by Mr. Arruda’s pre-existing medical conditions. This conclusion is “not undermined because Dr. Laposata’s opinion differed.”
The Court also noted that when determining whether Plan Administrators abuse their discretion, precedent does require it to determine “how we would read the plan de novo.” Accordingly, it held that, “Zurich’s determination that Mr. Arruda’s death was caused or contributed to by pre-existing medical conditions was supported by substantial evidence and was not arbitrary and capricious.”
This case was not handled by our firm, but we believe it can be helpful for those pursuing a claim for accidental death benefits. If you have any questions about this case, or about your own claim, contact one of our attorneys at Dell & Schaefer for a free consultation.
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