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McGuiggin v. Zurich American Insurance Co.

United States District Court, D. Massachusetts

March 25, 2019



          Leo T. Sorokin, United States District Judge.

         This action arises out of a claim for accidental death and dismemberment benefits, under a group policy issued by Zurich American Insurance Company, following the death of Kelly McGuiggin's son from acute fentanyl intoxication. Zurich rejected McGuiggin's claim after determining that the death was not accidental and, in any event, was excluded from coverage under the policy. McGuiggin sued Zurich in Massachusetts state court; Zurich removed the action to this Court. The parties seek entry of judgment on an agreed-upon record. For the reasons set forth below, McGuiggin's motion for summary judgment is DENIED, and judgment is ENTERED in favor of Zurich.

         I. BACKGROUND[1]

         McGuiggin is a Massachusetts resident and an employee of Sysco Corporation. She is insured by Zurich under a Group Accident Policy (“the Policy”) issued to Sysco on January 1, 2013. Doc. No. 32 at 231. The Policy provides an accidental death benefit in the event a covered person suffers a “Covered Injury” and dies.[2] Id. at 237. A “Covered Injury” is “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 235. 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 contains “General Exclusions, ” one of which is relevant:

A loss will not be a Covered Loss if it is caused by, contributed to, or results from: . . . (8) being under the influence of any prescription drug, narcotic, or hallucinogen, unless such prescription drug, narcotic, or hallucinogen was prescribed by a physician and taken in accordance with the prescribed dosage.

Id. at 242. The Court will refer to this provision as “Exclusion 8.”

         In January 2016, McGuiggin's son, Colin Gear, was a twenty-year-old student at the University of Massachusetts Dartmouth. Campus police conducted a wellness check at Gear's dorm room on January 29, 2016, sometime after 10:00 p.m. Id. at 49. After gaining entry to his locked room, the officers discovered Gear alone, lying naked on his bed, “unresponsive and cold to the touch.” Id. He was pronounced dead by paramedics who arrived on the scene soon thereafter. Id. On a desk in Gear's room, officers observed “a single ‘line' of a tan powdery substance, ” along with a “rolled-up twenty dollar bill, ” “the knotted portion of a clear plastic baggie, ” and a school identification card with “a powdery substance along its edge.” Id.

         Gear's roommates had last seen him the previous evening. Id. They reported to police that “they had suspected that [Gear] used some type of drug, ” as “they could hear snorting/sniffing sounds coming from [his] room” at times, and he had “appeared to be under the influence of something” on several occasions. Id. Gear's father, who had requested the wellness check, told police that Gear had admitted a heroin addiction to him the previous spring. Id.

         Based on these circumstances, the initial police report regarding Gear's death described the “possible manner of death” as “heroin overdose.” Id. at 50. A medical examiner performed an autopsy. Both the autopsy report and the death certificate reflect the medical examiner's conclusion that the cause of Gear's death was “acute fentanyl intoxication, ” and the manner of death was an “accident” that occurred due to “substance abuse” or “snorting illicit drugs.” Id. at 23, 26. As part of the autopsy process, Gear's blood was tested for the presence of various substances; the resulting toxicology report reflects a positive result for fentanyl. Id. at 30.

         McGuiggin notified Zurich of Gear's death on April 20, 2016 and requested the forms necessary to make a claim under the Policy.[3] Id. at 14. On June 28, 2016, she submitted her claim, providing a completed Proof of Death form, along with copies of Gear's death certificate, autopsy report, and related police reports. Id. at 16-78. After requesting pharmacy records for Gear and confirming he had no active prescription for fentanyl, id. at 163, 169, Zurich denied McGuiggin's claim by letter dated September 20, 2016, id. at 154-57. The denial rested on Zurich's conclusion that Gear's death was “not a Covered Loss due to a Covered Injury, ” and that two coverage exclusions applied: an exclusion for suicide, and Exclusion 8. Id.

         McGuiggin appealed the denial to Zurich on December 9, 2016, arguing that Gear's death was accidental, that there was no evidence to suggest suicide, and that Exclusion 8 applied only to “prescription” drugs and not to “illicit” drugs. Id. at 8-12. Zurich's ERISA committee reviewed the claim, meeting at least twice to discuss it and requesting a legal opinion on the applicability of Exclusion 8. Id. at 270, 273-75. Ultimately, the committee affirmed the denial of coverage in a March 29, 2017 letter, citing Exclusion 8 but no longer invoking the suicide exclusion. Id. at 267-69.

         In June 2017, McGuiggin sued Zurich in the Dukes County Superior Court, alleging breach of contract, seeking a declaratory judgment, and claiming violations of state consumer protection laws. Doc. No. 1-3. Zurich removed the action to this Court on August 16, 2017, noting the Policy is subject to the Employee Retirement Income Security Act of 1974 (“ERISA”), and therefore characterizing McGuiggin's action as one arising under federal law.[4]Doc. No. 1. McGuiggin concedes that ERISA governs the Policy, Doc. No. 33 at 1 n.2, and she has not opposed Zurich's assertion that ERISA preempts the state-law claims in her original complaint, see Doc. No. 34 at 18 (citing decisions finding that ERISA preempts chapter 93A and breach-of-contract claims related to the denial of benefits under ERISA plans). As such, this Court considers McGuiggin's action as one to enforce her rights under the Policy pursuant to 29 U.S.C. § 1132(a). Wickman v. Nw. Nat'l Ins. Co., 908 F.2d 1077, 1081-82 (1st Cir. 1990).

         The parties urged the Court to resolve McGuiggin's claims on the pleadings and an agreed-upon record of relevant documents, with McGuiggin filing an opening motion and brief, Zurich responding, and McGuiggin replying. Doc. Nos. 27, 32. After reviewing those briefs and the record, the Court requested additional information regarding whether and how McGuiggin received the Policy. Doc. No. 38. The ...

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