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Jones v. AIG Claims Services

October 16, 2007

JAMES JONES
v.
AIG CLAIMS SERVICES, INC.



The opinion of the court was delivered by: Dennis H. Inman United States Magistrate Judge

MEMORANDUM OPINION

Plaintiff's employer, Nuclear Fuel Services, Inc., purchased a group accident insurance policy for the benefit of its employees. The accidental death insurance policy was an "employee benefit plan" as defined in the Employee Retirement Income Security Act as codified in 29 U.S.C. § 1001, et seq. The plaintiff Mr. Jones elected, on behalf of himself and his wife, to enroll in the plan as beneficiaries. The accidental death policy was underwritten by AIG Life Insurance Company. AIG Claims Services, Inc. was the administrator of the plan.

Mrs. Jones died on September 21, 2003. Mr. Jones, claiming that his wife died as the result of an accident, filed a claim under the AIG policy. The plan administrator denied his claim, prompting Mr. Jones to seek judicial review pursuant to 29 U.S.C. § 1132(a). Both parties have moved for summary judgment on the basis of the administrative record. (Docs. 13 and 15).

Judicial review of a denial of benefits under an ERISA plan is de novo, unless the plan gives the plan administrator discretionary authority to determine eligibility for benefits, or to construe the terms of the plan. Firestone Tire & Rubber v. Bruch, 489 U.S. 101 (1989). It is undisputed that the plan administrator, AIG Claims Services, Inc., did not have discretionary authority to determine a beneficiary's eligibility for benefits, or to construe terms of the plan. Therefore, this court will review de novo the record upon which the administrator denied benefits to Mr. Jones.

The accidental death policy issued by AIG to Mr. Jones' employer contained the following pertinent provisions:

Accidental Death Benefit. If injury to the Insured Person results in death within 365 days of the date of the accident that causes the Injury, the Company will pay 100% of the Principal Sum.

Injury - means bodily injury caused by an accident occurring while this Policy is in force as to the person whose Injury is the basis of claim resulting directly and independently of all other causes in a covered loss.

Exclusions - This policy does not cover any loss caused in whole or in part by, or resulting in whole or in part from, the following:

(2) Sickness, disease or infections of any kind; except bacterial infections due to an accidental cut or wound, botulism, or ptomaine poisoning . . . . [Italics supplied].*fn1 The policy's definition of Injury is incredibly awkward, but apparently no one disagrees regarding its intent: a death, to be covered by the policy, must be caused solely by an accident and nothing else may play a role, however minor, in the death.

All the facts, save the dispositive one, are undisputed. In 2003, Mrs. Jones was treated by Slonaker Medical Associates of Erwin, Tennessee for various ailments, including arteriosclerotic disease.*fn2 Slonaker's records also reflect that Mrs. Jones sustained a fall in April or May 2003 which caused her significant pain.*fn3 Slonaker's office note of May 7, 2003, indicates that Darvocet had not relieved her pain.*fn4 She continued to complain of pain in her legs and back in July 2003.*fn5 The doctor's note regarding a September 19, 2003, visit reflects that Mrs. Jones had been prescribed Darvon.*fn6 In some way Mrs. Jones managed to obtain two separate prescriptions for Darvon, both of which she had filled.*fn7 She died on September 21, 2003, while visiting relatives in Ohio.*fn8

An autopsy was performed by the office of the Lucas County, Ohio Coroner on September 22, 2003.*fn9 A synopsis of that autopsy is set forth in a "Case Summary On The Death Of Peggy Jones."*fn10 First, the examining pathologists found that Mrs. Jones had relatively severe arteriosclerotic cardiovascular disease; the right coronary artery was 80-90% occluded, and the left anterior descending coronary artery was 50% occluded. Secondly, a toxicology analysis of Mrs. Jones' blood revealed 1.6 mcg/ml of Propoxyphene in her blood, and 4.5 mcg/ml of Norpropoxyphene (the metabolite of Propoxyphene). Propoxyphene is popularly known as Darvon, and Mrs. Jones had ingested an overdose. Presumably in an effort to alleviate her pain, Mrs. Jones took enough Darvon that it reached toxic levels in her blood. The autopsy report indicated that Mrs. Jones' "cause of death" was occlusive coronary artery disease which was "due to" arteriosclerotic cardiovascular disease. The report further stated that a "significant condition" was "combined drug overdose" as a result of ingesting a combination of multiple prescription medications. The manner of death was reported to be an "accident."*fn11

Mr. Jones filed a claim under the AIG Accidental Death Policy on the basis that his wife's death was due to an accidental overdose of Propoxyphene. The plan administrator denied the claim, stating that Mrs. Jones' death was not the result of an injury that resulted "directly and independently of all other causes." In other words, AIG argues that Mrs. Jones occlusive coronary artery disease was the cause of her death, or at least contributed to it.

The plan administrator relies upon the autopsy report of the Lucas County Coroner's Office which says that Mrs. Jones died of occlusive coronary artery disease, and that the accidental overdose of Propoxyphene was merely a "significant condition." The plan administrator also relies upon the opinion of Dr. Joye Carter, a pathologist and "Forensic Consultant" who asserts that the overdose of Darvon only played an "accessory role" in Mrs. Jones' death.*fn12 In other words, Dr. Carter was and is of the opinion that the Darvon overdose may have been an exacerbating factor as far as Mrs. Jones' death is concerned, but it was not the cause of her death; rather, her death was the result of the occlusive coronary artery disease or, at the most, the combined result of the coronary artery disease and the drug overdose.

Mr. Jones relies on the Lucas County Coroner's Report to the extent that it recites that Mrs. Jones' death was accidental. He also relies upon the opinions of Dr. Shannon McCool, a pharmacologist; Dr. Joe Bailey, a cardiologist; and Dr. Cleland Blake, a pathologist, all of whom state with varying degrees of certainty that Mrs. Jones' heart stopped as a result of the ...


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