Miller v. Hartford Life & Acc. Ins. Co.,
2010 U.S. Dist. LEXIS 24717 (N.D. Ga. Mar. 17, 2010)
Miller’s husband was a participant in an ERISA-governed accidental death and dismemberment plan sponsored by his employer. While swimming laps at a community pool, “he suddenly grimaced and submerged” under the water.
When paramedics arrived on the scene, Miller’s husband was in cardiac arrest and was breathing abnormally. Although he had a pulse when the paramedics arrived, he died shortly thereafter.
The medical examiner concluded that it was likely that the decedent “experienced a cardiac event that resulted in his becoming submerged while swimming, which was consistent with a natural disease process occurring in a hostile environment (i.e., the water of a swimming pool), resulting in [the decedent’s] death.”
In order to qualify for AD&D benefits under the plan, the decedent’s death had to be caused by “bodily injury resulting directly and independently of all other causes from an accident …” Hartford denied Miller’s claim for benefits because it determined that the decedent’s death was not the direct result of an injury, independent of all other causes.
Reviewing Hartford’s decision under the arbitrary and capricious standard, the district court first conducted a de novo review of the claim decision. It noted that in the context of accidental death claims, the Eleventh Circuit has adopted the “substantially contributed” test, which states that “a pre-existing infirmity or disease is not to be considered as a cause unless it substantially contributed to the disability or loss.”
Accordingly, the court concluded that Hartford’s decision was not de novo wrong, given that the administrative record supported its conclusion that a cardiac event due to heart disease was a substantially contributing cause of the decedent’s death, and therefore, the facts were “entirely consistent with Hartford’s determination that [the decedent] did not die from drowning with no other substantial cause.” The court therefore denied Miller’s motion for summary judgment, and granted Hartford’s motion for trial on the papers.
Click Here to view the full May 2011 Edition of the ERISA and Life Insurance News.