Prather v. Sun Life Financial Distributors, Inc.

Filing 25

OPINION entered by Judge Richard Mills on 3/29/2016. The Defendant's Motion for Summary Judgment, d/e 17 is ALLOWED. The Plaintiff's Motion for Summary Judgment, d/e 18 is DENIED. Judgment to be entered in favor of the Defendant. Case CLOSED. (MAS, ilcd)

E-FILED

Tuesday, 29 March, 2016 09:09:16 AM
Clerk, U.S. District Court, ILCD

IN THE UNITED STATES DISTRICT COURT
FOR THE CENTRAL DISTRICT OF ILLINOIS
SPRINGFIELD DIVISION
LEE ANN PRATHER,

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Plaintiff,
v.
SUN LIFE FINANCIAL
DISTRIBUTORS, INC.,
Defendant.

NO. 14-3273

OPINION
RICHARD MILLS, U.S. District Judge:
This is an action for declaratory judgment, pursuant to 28 U.S.C. §§
2201 and 2202, and other relief.
Both parties have moved for Summary Judgment.
I. INTRODUCTION
This case is brought pursuant to ERISA § 502(e)(1) & (2), as well as
29 U.S.C. § 1132. Plaintiff Lee Ann Prather is an individual domiciled in
Sangamon County, Illinois. Defendant Sun Life and Health Insurance
Company (U.S.) is a corporation organized and existing under the laws of
the State of Connecticut, and doing significant business in Illinois.

Plaintiff Lee Ann Prather asserts she is entitled to accidental death
and dismemberment benefits on her husband Jeremy Prather’s life. The
accidental death benefits were pursuant to Mr. Prather’s employer welfare
benefit plan (“Plan”) funded by Group Life Insurance Policy No. 54-0000
(“Policy”) issued by Defendant Sun Life Financial Distributors, Inc.
The Policy was issued to the Springfield Urban League, Inc., her
husband’s employer. The Plaintiff alleges that Jeremy Prather sustained an
injury during a pickup basketball game which eventually led to his death.
As a result, the Plaintiff asserts she is entitled to recover accidental death
benefits under the policy, in addition to reasonable attorney’s fees in
connection with the prosecution of the claim.
The Defendant alleges Jeremy Prather’s death was attributable to
natural causes and not the result of an accident.
II. FACTUAL BACKGROUND
(A)
Jeremy Prather was hired on December 8, 2011 by the Springfield
Urban League, Inc., as a Coordinator. Incident to his employment, Mr.

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Prather participated in the Plan with basic life insurance and accidental
death benefits funded by the Policy issued by Sun Life, which also served
as the Plan’s claims review fiduciary. The Plan is subject to ERISA.
At all relevant times, Mr. Prather was an employee of the Springfield
Urban League and was an insured eligible for benefits under the Policy.
The group insurance coverage issued to Springfield Urban League, Inc.
insures basic life and accidental death and dismemberment benefits
afforded under the Springfield Urban League, Inc.’s Plan. Mr. Prather’s
insurance coverage under the Group Policy includes an accidental death
benefits clause, stating:
Accidental Death and Dismemberment Benefit
We will pay a benefit based on the amount shown in the
Insurance Schedule if, while you are insured under the policy,
you sustain bodily injuries:
1.
That result directly from an accident and independently
of all other causes;
2.
That, within 365 days of the date of the accident, result
in one of the losses listed below; and
3.
That are not excluded in the “Restrictions” section below.
Restrictions
We will not pay a benefit for any loss that is caused, either
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directly or indirectly, or contributed to, by:
1.

Physical or mental infirmity or disease.

[. . .]
7.

Medical or surgical treatment.

Mr. Prather carried accidental death and dismemberment benefits in an
amount 200 percent of his basic annual earnings, amounting to
$93,814.79.
The Policy contains a discretionary clause which provides, in
pertinent part, as follows:
Claims Fiduciary
Sun Life and Health Company (U.S.) as Claims Fiduciary, shall
have the sole and exclusive discretion and authority to carry out
all actions involving claims procedures explained in the Policy.
The Claims Fiduciary shall have the sole and exclusive
discretion and power to grant and/or deny any and all claims for
benefits, and construe any and all issues relating to eligibility
for benefits. All findings, decisions, and/or determinations of
any type made by the Claims Fiduciary shall not be disturbed
unless the Claims Fiduciary has acted in an arbitrary and/or
capricious manner. Subject to the requirements of law, the
Claims Fiduciary shall be the sole judgment of the standard of
proof required in any claims for benefits and/or in any question
of eligibility for benefits.

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R. 35.
On or about July 16, 2013, Mr. Prather sustained a ruptured left
Achilles tendon while playing basketball. The Plaintiff alleges Mr. Prather
further developed deep vein thrombosis and a pulmonary embolism as a
direct result of the accident-related injury. The Defendant asserts Mr.
Prather developed deep vein thrombosis and pulmonary embolism
subsequent to surgical repair of his ruptured Achilles tendon.
Following Mr. Prather’s basketball-related injury, Rishi Sharma, M.D.,
discussed deep vein thrombosis and pulmonary embolism with him. On
July 16, 2013, Mr. Prather was provided with a CAM walker with a heel lift
as well as with crutches. Mr. Prather received a prescription for Vicodin.
Dr. Sharma discussed immobilization as well as weight bearing as tolerated
and he recommended further consultation and evaluation with Orthopedic
Surgery.
On July 21, 2013, Mr. Prather reported by telephone call to the office
of Jeffrey Schopp, M.D., that he experienced lower left extremity swelling

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starting one or two days after rupturing his Achilles tendon.1 Mr. Prather
denied redness, streaking, or discoloration, fever or chills, shortness of
breath or chest pain and indicated he was ambulating with a boot and
crutches. He further stated that elevation seemed to decrease the swelling
slightly and “there is an area on the outer aspect of his left calf that is more
sensitive than the rest of his calf.”

Mr. Prather also stated he was

concerned about a blood clot. He was advised to keep his leg elevated
above the level of his heart and that he would be evaluated the following
day prior to his surgery.
Mr. Prather was evaluated by Dr. Schopp prior to surgery. The
surgery to repair Mr. Prather’s ruptured Achilles tendon went forward on
July 22, 2013, with no operative complications. The procedural notes
provide that Dr. Schopp discussed anesthetic complication, infection,
neurovascular injury, re-rupture, deep vein thrombosis, pulmonary
embolism and the usual postoperative course. Mr. Prather and his family

The Defendant states that Mr. Prather’s swelling started a day after the
basketball-related injury, or four days prior. However, the doctor’s notes say
that the injury was six days prior and the swelling began four days ago.
1

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stated that they understood the procedure, had an opportunity to ask
questions and gave consent.
On August 2, 2013, Mr. Prather presented for staple removal and was
told to follow up in four weeks or sooner if any problems occurred. On or
about August 6, 2013, Mr. Prather passed away. Mr. Prather’s death
resulted minutes after a pulmonary embolism and three weeks after he
ruptured his Achilles tendon. In describing the injury, the Certificate of
Death provides that while Mr. Prather was playing basketball, another
player stepped on his ankle, causing the tendon to rupture. It further
indicates the cause of death as “accidental,” with Postmortem Report
describing the same as “pulmonary embolism due to deep vein thrombosis
due to left Achilles tendon rupture.”
Immobilization alone is a risk factor for deep vein thrombosis leading
to a pulmonary embolism.

Even with conservative treatment, which

includes non-weight bearing and immobilization, the insured was at a
greater than standard risk of blood clot. Accordingly, there were risks
associated with both surgery and conservative treatment.

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(B)
The Plaintiff is Mr. Prather’s primary beneficiary under the Policy and
would be entitled to recover accidental death benefits. She submitted a
timely claim for accidental death benefits under the Policy.
The Defendant has denied the Plaintiff’s claim for accidental death
benefits, a decision which it upheld upon appeal.

The Plaintiff has

exhausted the Plan’s administrative appeals process.
The autopsy report dated September 1, 2013, revealed bilateral
thromboemboli within the right and left pulmonary arteries. “The wellformed, maroon, cylindrical blood clots measure up to 1.5 cm diameter and
extend deep into the smaller arterial branches of each lung. [. . .] Cut
sections show soft tissue that exudes moderate amounts of congested blood
and edema fluid, along with smaller thromboemboli within the smaller
artery branches.” The autopsy additionally identified blood clots within the
deep veins of Mr. Prather’s left leg. Forensic Pathologist Amanda J.
Youmans, D.O., opined that Mr. Prather’s immediate cause of death was
pulmonary embolism, due to deep vein thrombosis occurring days earlier,

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due to, or as a consequence of his left Achilles tendon rupture weeks earlier.
In correspondence dated October 25, 2013, Sun Life expressed its
condolences for the Plaintiff’s loss and forwarded a check in the amount of
$93,814.79 in full payment of the group basic life insurance benefits due
under the Policy. The Defendant further informed the Plaintiff that in
order to review her claim for accidental death benefits, it required a copy
of Mr. Prather’s complete medical records concerning his initial accident on
July 16, 2013 and all subsequent treatment including his surgery on July
22, 2013, through his death on August 6, 2013. Sun Life followed up with
the Plaintiff for the requested information on November 25, 2013, and
telephonically on December 3, 2013.
On or about December 10, 2013, the Defendant received the
requested information. The Defendant notes that Dr. Schopp discussed
non-operative treatment in a cast versus surgical reapproximation of the
tendon. Dr. Schopp discussed the possibility of infection, neurovascular
injury, deep vein thrombosis, pulmonary embolism, and the usual
postoperative course with Mr. Prather. The medical records reveal that Mr.

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Prather was “motivated” to proceed with surgery for a multitude of reasons
and understood the potential complications. Mr. Prather and his wife gave
consent for surgery.
On December 17, 2013, Sun Life forwarded the medical records
received as well as the death certificate and autopsy report for a medical
review. The Defendant requested answers to the following questions:
•

Based on the information included on the death certificate,
autopsy report and medical records is it safe to conclude that
Mr. Prather died of a direct result of his accident/left Achilles
Tendon rupture, making this a truly accidental death?

•

Can we conclude that his subsequent surgery to repair the
tendon rupture played no part in the DVT/Pulmonary
Embolism that caused his death?

On December 18, 2013, Sun Life received a written death claim review
prepared by Wendy Haering, PA-C, CDMS. Ms. Haering provided the
following answers to the above questions:
[. . .] Answer: The condition that prompted medical care was an
accidental injury to the L Achilles tendon on 7/16/2013. The
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claimant chose surgical repair instead of conservative
management. He was advised of the risks of intervention
including DVT/PR. On 7/21/13 he called the orthopedic
surgeon’s office to report that the swelling in his leg had not
decreased, and was now associated with warmth and tenderness.
He was worried about a blood clot. He was advised to elevate
his leg for the remainder of the day. Plans were made for
further evaluation on 7/22/13 prior to surgery. The surgery was
performed on 7/22/13. There were no operative complications.
Post operatively, the insured appeared well and his staples were
removed on 8/2/2013. There is documentation of a traumatic
accident as the proximate cause of the events leading to surgery,
and complications from surgery (DVT/PE)
[. . .]
Answer: No. As Dr. Schopp discussed with the insured, the
risks of surgery included DVT and PE.
That said,
immobilization alone is a risk factor for DVT/PE. Even with
conservative treatment, which includes non-weight bearing and
immobilization, the insured was at greater than standard risk of
a blood clot. It’s clear from the records that he understood this
risk as he voiced his concern about having a blood clot one day
before his surgery.
On January 6, 2014, Sun Life received medical records pertaining to
the care Mr. Prather received on August 6, 2013, prior to his death. The
medical records revealed that Mr. Prather fell at work from a standing
position and coded during the transport to the hospital. Mr. Prather was
in cardiopulmonary arrest on arrival at the hospital.
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On January 17, 2014, the Defendant denied the Plaintiff’s claim,
explaining:
[. . .] To be eligible for Accidental Death Group Benefits under
this policy, an insured must sustain bodily injuries that result
directly from an accident and independently of all other causes.
Further, in the restrictions section it is stated that we will not
pay for any loss that is caused or contributed to, by medical or
surgical treatment. Jeremy Prather fully understood the risks
and possible complications of surgical treatment including Deep
Vein Thrombosis and Pulmonary Embolism, and subsequently
gave consent for surgical treatment. Therefore, as it appears
that Jeremy Prather’s death was as a result of complications
from surgical treatment, we must inform you that no Accidental
Death Group Benefit is due under this group policy. [. . .]
On or about February 10, 2014, the Plaintiff, through counsel,
submitted an appeal, admitting that the cause of Mr. Prather’s death was
a “known complication of the medical treatment.” The Plaintiff contended,
however, that the necessity for the medical treatment was the “accident
itself” and that the Certificate of Death listed the death as an “accident”
which, according to the Plaintiff, entitled her to benefits. The Plaintiff did
not advance any other arguments or address the Policy’s restrictions
language.
In correspondence dated February 20, 2014, the Defendant
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acknowledged the Plaintiff’s appeal. On April 15, 2014, Sun Life upheld
its previous denial of the Plaintiff’s claim for accidental death benefits. Sun
Life noted that treatment notes showed Mr. Prather was aware of the risks
associated with having surgery, in particular the potential for pulmonary
embolism. The Defendant further states that Plaintiff has acknowledged
that the cause of death was “a known complication of the medical
treatment.” Moreover, the Policy specifically states that Sun Life will not
pay an accidental death benefit if medical or surgical treatment, or surgical
treatment causes, directly or indirectly, or contributes in any way, to the
death of the insured.
Following the Defendant’s denial of the appeal, the Plaintiff filed the
instant lawsuit.
III. DISCUSSION
A. Legal standard
The Parties agree that the Court must review the decision to deny
benefits under an arbitrary and capricious standard. A denial of benefits
must be upheld as long as the denial has “rational support in the record.”

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Leipzig v. AIG Life Ins. Co., 362 F.3d 406, 409 (7th Cir. 2004). Therefore,
the Court will not disturb the decision if it was “based on a reasonable
interpretation of the plan’s language and the evidence in the case.” Russo
v. Health, Welfare & Pension Fund, Local 705, Intern. Broth. of Teamsters,
984 F.2d 762, 765 (7th Cir. 1993).
The Plaintiff has the burden of showing that Mr. Prather’s death
satisfied the Policy’s accidental death provisions. Because she seeks to
enforce benefits under the Policy, the Plaintiff must prove her “entitlement
to contract benefits.” See Ruttenberg v. U.S. Life Ins. Co., 413 F.3d 652,
663 (7th Cir. 2005). In order to show that the decision was arbitrary and
capricious, therefore, the Plaintiff must show that Mr. Prather’s death
resulted from bodily injuries sustained directly as a result of an
accident–independently of any other cause.
B. Whether denial was arbitrary and capricious
The Plaintiff contends that the Defendant’s decision to deny benefits
by attributing the cause of Mr. Prather’s death to medical treatment rather
than accident was arbitrary and capricious because the deep vein

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thrombosis occurred before his medical treatment. Prior to his surgery, Mr.
Prather contacted his physician to state he believed he had a blood clot in
his calf. Moreover, Sun Life admitted that immobilization alone is a risk
factor for deep vein thrombosis leading to a pulmonary embolism for which
Mr. Prather was at greater risk than standard risk of blood clot. Thus, the
Plaintiff alleges even conservative treatment involving non-weight bearing
and immobilization would have led to a greater than standard risk of blood
clot.
Accordingly, the Plaintiff contends that the medical procedure to
repair Mr. Prather’s Achilles tendon had no correlation, either directly or
indirectly, to the formation of the blood clot and thus contributed no part
in his death.

At the very least, Mr. Prather’s death was caused by

complications of a ruptured Achilles tendon. The Plaintiff asserts that if
complications of an accidental injury cause death, the law considers the
death to be an accident.
The Plaintiff cites Senkier v. Hartford, 948 F.2d 1050 (7th Cir. 1991)
in asserting that the denial of her claim was arbitrary and capricious. The

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court in Senkier observed, “In the old days courts distinguished between
accidental means and accidental result.” Id. at 1052. It further noted,
“Death is almost always accidental in the sense of unintended by the
deceased, so if an accidental result sufficed, coverage would be assured
regardless of the cause of death.” Id. Under the traditional view, the
beneficiary would not recover proceeds under an accident policy if “there
is nothing accidental in the means by which the person died.” See id.
The Court in Senkier went on to say, “It would be different if he
twisted his knee playing tennis and the injury caused blood clots that
embolized to his lungs and killed him. . . . Then the means of death–the
injury to the knee–would be an accident, and the death would be covered.”
Id. The Plaintiff alleges that Mr. Prather’s injury and resulting death is
analogous to the situation described in Senkier.
Although there is a similarity between Judge Posner’s hypothetical
regarding an individual’s tennis-related injury and Mr. Prather’s ruptured
Achilles tendon playing basketball, this Court is not interpreting the same
policy as the court in Senkier. The policy in Senkier “offer[ed] full 24 hour

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protection against accidents anywhere in the world, whether you are on
business, pleasure, vacation, at home, or on or off the job.” Id. at 1051.
The policy excluded “sickness or disease” and “medical or surgical
treatment of a sickness or disease.” Id. The court observed that the policy
did not address “whether a mishap in the course of treatment should be
classified as part of the treatment itself or as an accident.” Id.
In this case, because the Policy specifies that the “bodily injuries”
must “result directly from an accident and independently of all other
causes” and, further, that Sun Life “will not pay a benefit for any loss that
is caused, either directly or indirectly, or contributed to by . . . Medical or
surgical treatment,” the Court need not look beyond the words of the
Policy. Clearly, Senkier is inapposite.
Here, the Policy unambiguously requires Sun Life to deny coverage
and benefits if it determined that medical or surgical treatment, either
directly or indirectly, contributed to Mr. Prather’s death. The Defendant
notes that, during the administrative review of the claim, the Plaintiff
acknowledged that Mr. Prather died of a known complication of the

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surgical repair of his ruptured Achilles tendon. Given that admission, it is
difficult to see how the Court could conclude that Sun Life’s decision to
deny the Plaintiff’s claim could be found to be arbitrary and capricious.
To the extent that Plaintiff now contends Mr. Prather developed the
clot which led to his deep vein thrombosis and pulmonary embolism prior
to any medical intervention, there is no medical evidence in support of that
assertion. Although Mr. Prather described pain and swelling and expressed
concerns about developing a blood clot in his calf during a phone call to the
telenurse on July 21, 2013, there was no objective finding and the Court
declines to assume that a blood clot had developed.
Wendy Haering, PA-C, CDMS, determined that Mr. Prather’s
ruptured Achilles tendon was the proximate cause of the events leading to
surgery and the complications from surgery, which led to his death. It is
almost certain that, but for the basketball-related injury, Mr. Prather would
not have needed surgery. However, it is also undisputed that the surgical
treatment he received contributed to his death.

The record further

establishes that Mr. Prather acknowledged he knew the risk of developing

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deep vein thrombosis and pulmonary embolism as a result of the procedure.
Although there was also an increased risk of a blood clot associated
with

conservative

treatment,

including

non-weight

bearing

and

immobilization, that does not change the result here which is based on the
language of the Policy.
Based on the foregoing, including the Plaintiff’s acknowledgment that
Mr. Prather’s death could be attributed, at least in part, to complications
from surgery and Ms. Haering’s finding that such complications
contributed to Mr. Prather’s death, Sun Life had a reasonable basis to deny
the benefit because his death did not “result directly from an accident and
independently of all other causes.” Moreover, Sun Life had a legitimate
basis to find that the loss was caused, at least “indirectly, or contributed to”
by “Medical or surgical treatment.” Sun Life’s denial of the claim is
consistent with the language of the Policy. Accordingly, the denial has
rational support in the record.
The Court cannot without medical evidence assume that, based on his
pain and swelling described in the call to the telenurse on July 21, 2013,

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Mr. Prather developed deep vein thrombosis prior to surgery. Because it
was not discovered by Dr. Schopp prior to surgery on July 22, 2013, Sun
Life had a reasonable basis to conclude that medical treatment contributed
to Mr. Prather’s death.
Accordingly, the Court cannot conclude that the Defendant’s decision
was arbitrary and capricious.
C. Conflict of interest
The Plaintiff also contends that Sun Life’s decision to deny benefits
was an abuse of discretion, given the Defendant’s inherent conflict of
interest as a fiduciary that both evaluates claims for benefits and pays out
the same benefits. A conflict of interest exists when a plan administrator
has both the discretionary authority to determine eligibility for benefits and
the obligation to pay benefits when due. See Metropolitan Life Ins. Co. v.
Glenn, 554 U.S. 105, 108 (2008).
It is common in ERISA cases for the plan administrator to also be the
payor of claims. See Edwards v. Biggs & Stratton Retirement Plan, 639
F.3d 355, 364 (7th Cir. 2011). Because there is a conflict of interest in the

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overwhelming majority of ERISA cases, the Seventh Circuit has held it is
not the existence of a conflict that is significant. See id. The gravity of the
conflict, based on the circumstances of the case, is the crucial factor. See
id. The Seventh Circuit has also held:
[T]he gravity of the conflict, and thus the likelihood that the
conflict influenced the plan administrator’s decision, should be
inferred from the circumstances of the case, including the
reasonableness of the procedures by which the plan
administrator decided the claim, any safeguards the plan
administrator has erected to minimize the conflict of interest,
and the terms of employment of the plan administrator’s staff
that decides benefit claims.
Majeski v. Metropolitan Life Ins. Co., 590 F.3d 478, 482 (7th Cir. 2009)
(citation omitted). The Supreme Court has suggested that a plan’s conflict
of interest might be a tiebreaker if “circumstances suggest a higher
likelihood that [the conflict] affected the benefits decision, including, but
not limited to, cases where an insurance company administrator has a
history of biased claims administration.” Glenn, 554 U.S. at 117.
The Court concludes that no circumstances suggest that Sun Life’s
conflict of interest affected the denial of benefits. The Defendant provided
the Plaintiff with a thorough review, including a request for a consultant’s
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opinion. The questions asked of the consultant tracked the language of the
Policy, including whether Mr. Prather’s death was a “direct result” of the
accident, and whether it can be concluded that the surgery played “no part
in the DVT/Pulmonary Embolism that caused his death.” The inquiries
were objective and plainly designed to determine whether the Defendant
was obligated to pay the benefit based on the Policy language.
The Plaintiff contends that, in determining whether there was an
abuse of discretion because of the conflict of interest, the Court should
consider factors such as Mr. Prather’s immobilization which led to swelling
and tenderness, causing “Mr. Prather to believe he had clot.” This suggests
that medical intervention did not directly or indirectly contribute to Mr.
Prather’s death, and a decision to deny benefits is arbitrary and capricious.
The Court cannot rely on speculation. There is no record evidence to find
that Mr. Prather had a blood clot prior to surgery.
Sun Life took into account the records of Mr. Prather’s medical
treatment, his surgery and the autopsy report. The Defendant also relied
on the independent review performed and the Policy language. Sun Life

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also approved the Plaintiff’s claim for death benefits and paid benefits as
mandated by the Policy.
There is no evidence suggesting that the conflict of interest affected
the denial of benefits. The conflict of interest did not lead to an arbitrary
and capricious decision.
The Court certainly has sympathy for Mrs. Prather’s tragic loss.
Because Sun Life’s decision was based on a reasonable interpretation of the
Policy’s language and the evidence in the case, however, the denial of
benefits was not arbitrary and capricious.
Ergo, the Defendant’s Motion for Summary Judgment [d/e 17] is
ALLOWED.
The Plaintiff’s Motion for Summary Judgment [d/e 18] is DENIED.
The Clerk will enter Judgment in favor of the Defendant and
terminate this action.
ENTER: March 29, 2016
FOR THE COURT:
s/Richard Mills
Richard Mills
United States District Judge
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