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Pulmonary Embolism Not “Accident” – 4th Cir.

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  • Pulmonary Embolism Not “Accident” – 4th Cir.

    Pulmonary Embolism Not “Accident” – 4th Cir.

    Attached hereto is an unpublished case out of the Fourth Circuit, Grabowski v. Hartford Life & Accident Insurance Company. The case is before the court on appeal from the district court’s judgment for defendant. Mark Grabowski was covered under an ERISA governed AD&D policy. He passed away due to a pulmonary embolism. Plaintiff argued that Mark’s death was due to an accident and cites to several cases wherein various courts had determined that death due to pulmonary embolism was accidental. The Fourth Circuit disagreed.

    Linda faults the district court for allegedly failing to consider various Circuit and district court decisions she contends support the proposition that death resulting from a pulmonary embolism—the event listed in the medical examiner’s autopsy report and the death certificate as the condition or event resulting in Mark’s death—and similar conditions qualifies as accidental. But these cases are inapposite. In particular, her reliance on Yasko v. Reliance Standard Life Insurance Co., 53 F. Supp. 3d 1059 (N.D. Ill. 2014) is misplaced. The facts there involved a death similar to Mark’s, which the district court characterized as an “accident” under a similar policy. Id. at 1064. Critically, however, the court there was applying de novo review to the interpretation of the policy’s terms, rather than the abuse of discretion review we must apply here. Cf. Yasko on behalf of Yasko v. Standard Ins. Co., No. 12 C 2661, 2014 WL 2155227, at *1 (N.D. Ill. May 19, 2014) (addressing same facts under different AD&D policy that gave the administrator discretion to interpret terms of policy, and concluding that decision that the death was not accidental was not unreasonable).

    Linda also challenges as unreasonable Hartford’s interpretation of the terms accident and accidental in the AD&D policies. She contends that, under Wickman v. Nw. Nat’l Ins. Co., 908 F.2d 1077 (1st Cir. 1990), Mark’s death qualified as accidental. She contends that Hartford’s denial of her claims on the grounds that there was no evidence in Mark’s case of “traumatic” accidental injury was improper because that term is not present in the AD&D policies. She further contends that Hartford’s denial decision with respect to the basic AD&D policy essentially conceded that an accident occurred and that holding otherwise is improper.

    Under the abuse of discretion standard, however, Hartford only had to offer a reasonable, and not the most reasonable, interpretation of plan terms. See McCorkle v. Metro. Life Ins. Co., 757 F.3d 452, 459 (5th Cir. 2014) (explaining that abuse of discretion standard prohibits a court from “substituting [its] own, narrower interpretation of the term [“suicide”] in place of [the administrator’s] reasonable, yet broader, interpretation” (internal quotation marks omitted)). The policies under the plan condition AD&D benefits on the presence of an “accidental injury” and a “bodily injury resulting . . . directly from an accident.” Hartford determined these circumstances were not present because Mark died from the natural cause of a pulmonary embolism in the absence of any trauma. We defer to Hartford’s interpretation that these circumstances do not qualify as accidental. See King v. Penn. Life Ins. Co., 470 F. App’x 439, 444 (6th Cir. 2012) (No. 10-1672); Call v. Am. Int’l Grp., Inc., 621 F. Supp. 2d 352, 362 (S.D.W. Va. 2008). We further conclude that Wickman does not mandate a contrary result. See Erbe v. Conn. Gen. Life Ins. Co., 695 F. Supp. 2d 232, 254-55 (W.D. Penn. 2010) (agreeing that Wickman “does not lend itself to cases such as the one at bar involving deaths from heart attacks” and observing that cases applying Wickman were concerned with “distinguishing between a death from an intentional act . . . or from reckless behavior that the insured knew or should have known was likely to result in death, and death that was accidental because it was merely the result of negligent conduct” (internal quotation marks omitted)).
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