United States District Court, D. Massachusetts
MEMORANDUM AND ORDER
DOUGLAS P. WOODLOCK UNITED STATES DISTRICT JUDGE.
Arruda brings this action against Zurich American Insurance
Company (“Zurich”) seeking accidental death
benefits pursuant to an employee welfare benefits plan
stemming from the death of her husband, Joseph Arruda, in a
car accident. Zurich has denied benefits. The parties have
separately filed motions for judgment on the administrative
record. The parties do not contest the language or meaning of
the contract terms, but instead contest the sufficiency of
the record evidence to support Zurich's decision. Finding
that Zurich's decision is not supported by substantial
evidence, I will grant Mrs. Arruda's motion and deny that
Mr. Arruda's General Health
Arruda, age 57, worked as a salesperson for NSTAR in May of
2014. [Administrative Record (“R.”) at 3.] He had
been suffering from hypertension, hyperaldosteronism, and
hypertrophic cardiomyopathy. Mr. Arruda was obese, did not
exercise, and did not follow-up with physicians as
instructed. [Id. at 333, 335-36.] He also failed to
follow his prescription medication regimen. [Id.]
January 2014, Mr. Arruda passed out at home and was admitted
to the hospital the following day. [Id. at 151.] As
a result of that medical episode, he had a
ardioverter/defibrillator pacing device surgically implanted
in the left side of his chest in January 2014. [Id.
at 334.] Mr. Arruda's last medical examination by his
cardiologist, Christopher Abadi, M.D., on February 25, 2014,
included notes that Mr. Arruda had “done well from a
cardiac standpoint since” having the defibrillator
implanted and that his “blood pressure was fine.”
[Id. at 195.]
Arruda was insured under Basic Accident Policy No. GTU
4380194 (the “Policy”) issued by Zurich.
[Id. at 473.] The Policy provides, in relevant part
that: “If an Insured suffers a loss of
life as a result of a Covered Injury,
We will pay the applicable Principal
Sum.” [Id. at 96.] It defines a
covered injury as “an Injury directly
caused by accidental means which is independent of all other
causes, results from a Covered
Accident, occurs while the Covered Person is
insured under this Policy, and results in a Covered
Loss.” [Id. at 92.] A covered
accident is defined as “an Accident
that results in a Covered Loss.”
[Id.] An accident is “a sudden, unexpected,
specific, and abrupt event that occurs by chance at an
identifiable time and place during the
Policy term.” [Id.] Finally,
a covered loss is “a loss which meets the requisites of
one or more benefits or additional benefits, results from a
Covered Injury, and for which benefits are
payable under this Policy.” [Id.] The Policy
also contains two relevant exclusions: Exclusion 4, which
provides that a “loss will not be a Covered
Loss if it is caused by, contributed to, or results
from . . . illness or disease, regardless of how contracted .
. .” and Exclusion 8, which provides that a loss will
not be a covered loss if it is caused by, contributed to, or
results from “being under the influence of any
prescription drug, narcotic, or hallucinogen.”
[Id. at 102.]
The Car Accident
morning of May 22, 2014, Mr. Arruda was driving to the
University of Massachusetts-Amherst to attend a work event.
[Id. at 1.] At about 9:39 a.m., Mr. Arruda's car
crossed the highway median into oncoming traffic and struck
another car. [Id. at 147, 471.] The collision caused
Mr. Arruda's car to hit a curb, flip over multiple times,
and land upright. [Id. at 143.] CPR was performed on
Mr. Arruda. [Id. at 147.] He was pronounced dead on
the scene by the Hadley Fire Department. [Id.] The
autopsy report listed Mr. Arruda's cause of death as
hypertensive heart disease. [Id. at 834.] A
postmortem toxicology report found that Mr. Arruda had
marijuana in his system at the time of the crash.
[Id. at 842.]
The Attempt to Collect
about August 19, 2014, Mrs. Arruda filed for accidental death
benefits, as beneficiary of the Policy. [Id. at 52.]
Zurich then retained the services of an investigator, CS
Claims Group, Inc. (“CS Claims”), to investigate
the loss. [Id. at 109.] CS Claims investigated over
a period of eight months, providing Zurich with 17 reports
regarding its progress in collecting medical records, witness
statements, and medical examiner reports. [Id. at
125, 128, 132, 135, 189, 269, 331, 399, 400-402, 801, 802,
804, 831-33, 852.]
letter dated December 8, 2015, Zurich issued a denial of
benefits based on two grounds. [Id. at 473.] First,
Zurich concluded that Mr. Arruda's death was not the
result of an accidental bodily injury independent of all
other causes. [Id. at 475.] Second, and
independently, Zurich concluded that the Policy exclusion for
loss caused by, contributed to, or resulting from illness or
disease, was applicable. [Id.] Essentially, Zurich
concluded that Mr. Arruda's cause of death was
hypertensive heart disease such that Mr. Arruda's death
was not independent of an underlying medical condition.
[Id. at 474.]
January 29, 2016, Mrs. Arruda filed an appeal of denial with
Zurich. [Id. at 477.] In this appeal, Mrs. Arruda
submitted an Arrhythmia Logbook report from Boston
Scientific, the manufacturer of Mr. Arruda's implantable
cardioverter defibrillator; the hearing transcript from Mr.
Arruda's July 1, 2015 workers' compensation hearing;
and the workers' compensation lump sum settlement
agreement. [Id. at 477.] Mrs. Arruda supplemented
her appeal on August 24, 2016 with an expert report from
Elizabeth A. Laposta, M.D. [Id. at 1407-1424.]
appeals committee included four individuals who reviewed the
matter de novo. [Id. at 1786.] In assessing Mrs.
Arruda's claim, the appeals committee retained a medical
opinion from forensic pathologist Mark Taff, M.D.
[Id. at 1526.] Zurich submitted a letter to Mrs.
Arruda dated February 7, 2017, documenting Dr. Taff's
opinion as to Mr. Arruda's cause of death. [Id.
at 1584.] In sum, Dr. Taff concluded that Mr. Arruda died as
a result of accidental bodily injuries that were contributed
to by multiple pre-existing illnesses or diseases, which
caused him to lose control of his car and crash.
[Id. at 1599-1600.] Within the February 7 letter,
Zurich notified Mrs. Arruda that it might raise Exclusion 8
(contribution of drug use) of the Policy with regard to her
claim. [Id. at 1584.] Zurich explained that before
it issued its final decision, it would give Mrs. Arruda an
additional 30 days to review the material and provide any
input regarding the Exclusion 8 language. [Id.] On
April 17, 2017, Mrs. Arruda submitted Dr. Laposata's
response to Dr. Taff's report for Zurich's review,
which included a direct response to Zurich's application
of Exclusion 8. [Id. at 1697-1700.]
letter dated May 11, 2017, Zurich's appeals panel
affirmed the initial denial, concluding that Mr. Arruda did
not sustain a covered loss due to a covered accident, and
that the claim was also excluded based on Exclusions 4 and 8.
[Id. at 1727.] In that letter, Zurich explained that
the evidence indicated Mr. Arruda's death was caused by,
or resulted from, illness, disease, and use of marijuana.
[Id. at 1728.] Zurich's letter also included
explanations of the three medical reviews it relied on,
noting that William W. Angell, M.D., and Michael D. Bell,
M.D., both pointed to heart issues as the primary cause of
death, and that Dr. Taff concluded that Mr. Arruda's
health conditions were not the immediate cause of his death,
but “most likely triggered loss of control/erratic
driving . . . which resulted in fatal bodily injuries.”
to the terms of the Policy, Zurich is the administrator of
the Plan, and it has discretion to apply and interpret the
terms of the Plan in determining claims for benefits.
[Id. at 105.] Specifically, the Plan provides:
ERISA Claims Fiduciary. The
Policyholder agrees that the Policy
constitutes the plan and plan document under the Employee
Retirement Income Security Act of 1974 as amended (ERISA).
The Policyholder designates
Us as the claims fiduciary of this plan and
gives Us the discretionary authority to
determine eligibility for benefits and to construe the terms
of the plan. The Policyholder agrees to comply with the
disclosures and reporting requirements of ERISA regarding the
plan and Our designation and authority as
the claims fiduciary.
[Id.] “We” as defined in the Policy is
Zurich. [Id. at 93.]
addition to these proceedings, a dispute regarding the cause
of Mr. Arruda's death gave rise to a workers'
compensation hearing on July 1, 2015. [R. at 1290-97.] After
the hearing, the parties reached a lump sum settlement of Mr.
Arruda's workers' compensation claim. [Id.
The Record Evidence
Bell submitted a report to Zurich on November 30, 2015.
[Id. at 470.] That report, based on a compilation of
medical and non-medical records provided for review, which
included progress notes from Mr. Arruda's cardiologist
through February 2014, concluded that the crash and Mr.
Arruda's death “were caused by his heart disease,
whether it be due to hypertension or a variant of HCM.”
[Id. at 470-71.] Dr. Bell relied not simply on Mr.
Arruda's previous medical records, but also on the
autopsy performed by Dr. Sexton, which showed that Mr. Arruda
had “a C1 left posterior arch fracture and C3-C4
dislocation with soft tissue hemorrhage at the injury
sites.” [Id. at 471.] Dr. Bell found that this
fracture was a contributory cause of death. [Id.]
Dr. Bell also took into account Trooper David Sanford's
collision analysis, Trooper McMillan's report, and Dr.
Mindy Hull's cardiac pathology report. [Id.]