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Goetz v. Life Insurance Company of North America

United States District Court, E.D. Washington

September 21, 2017

MELISSA GOETZ, beneficiary and as Personal Representative of the Estate of Michael D. Greever, Plaintiff,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

          ORDER DENYING CROSS MOTIONS FOR SUMMARY JUDGMENT AND ENTERING JUDGMENT ON THE RECORD IN FAVOR OF DEFENDANT

          SALVADOR MENDOZA, JR. UNITED STATES DISTRICT JUDGE.

         On September 5, 2017, the Court held a hearing on the parties' cross motions for summary judgment, ECF Nos. 32 and 37. The Court denied both motions. The Court also heard oral argument on Ms. Goetz's underlying benefits claim and took the matter under advisement. This Order supplements and memorializes the Court's order on the motions for summary judgment and enters judgment in favor of LINA on the basis of the administrative record.

         I. INTRODUCTION

         This case arises from Ms. Goetz's claim for accidental death benefits following the death of her brother, Michael Greever. On October 11, 2015, Michael Greever was found dead in his mother's swimming pool. ECF No. 36-4 at 4. The medical examiner determined his cause of death was drowning, but there were no witnesses to the accident itself. ECF 36-2 at 83. Accordingly, it was not apparent what caused Mr. Greever's fall into the pool or why he failed to extricate himself from the water. The autopsy did not reveal any trauma to the head or neck, but the medical examiner noted Mr. Greever had a bite mark on his tongue. ECF No. 36-2 at 12. Because Mr. Greever had a history of epilepsy, the medical examiner presumed a seizure had precipitated the fall. ECF No. 36-1 at 111. The death certificate notes causes of death as “drowning” caused by “presumed epileptic seizure.” ECF No. 36-2 at 83.

         Shortly after Mr. Greever's death, Ms. Goetz submitted a claim for accidental death benefits under his Group Accident Policy No. OK 966394 (the Policy) with Life Insurance Company of North America (LINA). ECF No. 36-1 at 1. LINA denied Ms. Goetz's claim, finding Mr. Greever's death was not covered under the Policy. The Policy contains two “sole-cause” clauses that limit the scope of coverage. The first defines a Covered Loss as the “result, directly and independently of all other causes, of a Covered Accident.” Id. at 27. The second defines a Covered Accident as a sudden and unforeseeable accident that “is not contributed to by disease, Sickness, mental or bodily infirmity.” Id. LINA denied Ms. Goetz's claim, reasoning that the loss was not the result of a covered accident because Mr. Greever's fall was caused by an epileptic seizure. ECF No. 36-2 at 36. Ms. Goetz appealed, and LINA affirmed its decision. ECF No. 36-1 at 67.

         Both parties move for summary judgment under Federal Rule of Civil Procedure 56. Because a substantial issue of material fact exists as to whether Mr. Greever's epilepsy contributed to his drowning accident, summary judgment is not proper. LINA also moves for judgment under Rule 52. ECF No. 37 at 9. Because this is an ERISA case reviewing the plan administrator's decision de novo, judgment under on the record is proper in this case. There is some conflicting evidence regarding whether Mr. Greever suffered a seizure immediately prior to his drowning accident. However, the lack of physical evidence supporting an alternative explanation makes a seizure the most likely cause of death. Because Ms. Goetz has the burden to show Mr. Greever's epilepsy did not substantially contribute to his accident, entry of judgment in favor of the LINA is proper.

         II. BACKGROUND

         A. ERISA Policy

         LINA issued a Group Accident Policy No. OK 966394 to Mr. Greever's employer, Wagstaff, Inc. No. 36-1 at 15. The Policy is governed by ERISA. Id. at 45-46. The Policy provides accidental death benefits as follows:

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Covered Loss We will pay the benefit for any one of the Covered Losses listed in the Schedule of Benefits, if the Covered Person suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident within the applicable time period specified in the Schedule of Benefits.

Id. at 40. The Policy also includes the following definitions:

         Covered Accident A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and meets all of the following conditions:

1. occurs while the Covered Person is insured under this Policy;
2. is not contributed to by disease, Sickness, mental or bodily infirmity;
3. is not otherwise excluded under the terms of this Policy.

         Covered Loss A loss that is all of the following:

1. the result, directly and independently of all other causes, of a Covered Accident;
2. one of the Covered Losses specified in the Schedule of Covered Losses;
3. Suffered by the Covered person within the applicable time period in the Schedule of Benefits.

Id. at 27. The Policy contains the following sickness exclusion:

In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits Section:
* * *
7. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof . . . .

Id. at 32.

         B. Loss Facts and Investigation

         On October 11, 2015, Michael Greever was winterizing a swimming pool at his mother's home. ECF No. 36-4 at 4. Shortly before his death, his mother, Cindy Greever, observed Mr. Greever standing near the pool talking on the phone. Id. Ms. Greever then left the pool area and returned approximately five minutes later. Id. At that time, she discovered Mr. Greever floating face-down in the deep end of the pool. Id. There were no witnesses to the accident.

         Mr. Greever had a history of epilepsy resulting in tonic-clonic (grand mal) seizures. He also had a heart condition for which he was taking medication at the time of his death. See 36-3 at 115-16. Mr. Greever had not experienced a seizure in several years. ECF 36-1 at 111. Some records indicate his last seizure was eighteen years prior to his death. Id. However, an electroencephalogram (EEG) performed in 2005 indicated Mr. Greever had “spikes” and wave epileptiform complexes, making him at risk for future epileptic seizures. Id. Mr. Greever was prescribed seizure medication but had not filled the prescription since February 3, 2009. ECF No. 36-3 at 116.

         When police arrived, the investigating officer asked Ms. Greever about her son's medical history. Id. She advised the officer that Mr. Greever had suffered seizures until about ten years prior, at which time the seizures stopped and he was taken off medication. Id. She also advised the officer that Michael had not consumed alcohol that day, but had “tied one on” the previous evening and was tired. ECF No. 36-3 at 3. The investigating officer asked medical responders whether there was any sign Mr. Greever had hit his head and was told Mr. Greever had a mark on his right temple. Id. The officer then searched the edge of the pool and ladder railings for blood but found none. Id.

         Medical Examiner Sally Aiken, M.D. (Forensic Pathologist) for the Spokane County Office of the Medical Examiner performed an autopsy of Mr. Greever on October 13, 2015, two days after his death. ECF No. 36-1 at 110. In the accompanying autopsy report, the Medical Examiner summarized her case findings. The autopsy report indicated Mr. Greever had various cuts and bruises on his face, mouth, and body. Id. at 116. The report noted that some of the injuries may have been ...


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