HINKLE et al v. ASSURANT, INC. et al

Filing 14

MEMORANDUM AND/OR OPINION THAT PLAINTIFF'S MOTION FOR SUMMARY JUDGE WILL THEREFORE BE DENIED, AND DEFENDANT'S GRANTED. SIGNED BY HONORABLE JOHN P. FULLAM ON 5/12/09. 5/12/09 ENTERED AND COPIES E-MAILED.(afm, )

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA THOMAS M. HINKLE v. ASSURANT, INC. : : : : : MEMORANDUM Fullam, Sr. J. May 12, 2009 CIVIL ACTION

NO. 08-cv-04124-JF

Plaintiff's decedent was covered by a group insurance policy related to her employment, and the issue before the Court is whether the defendant insurance company should pay accidental death benefits under that policy, on account of the decedent's death. The issue is before the Court on motions for summary

judgment. Plaintiff's decedent was diagnosed with what turned out to have been a benign cyst on her kidney, and underwent surgery for its removal. Unfortunately, the surgeon committed

malpractice, and severed the wrong blood vessel, resulting in the decedent's death in the operating room. The defendant denied coverage, on the theory (1) that the death was not "accidental" and (2) that the death was the indirect result of disease, hence excluded from coverage under the policy. If I were free to do so, I would reject both of these defense theories. In my view, the operating surgeon did not

intentionally sever the wrong blood vessel, hence the decedent

was indeed the victim of an accident; and the benign cyst did not cause decedent's death in any way. But I can grant relief to

plaintiff only if the denial of coverage is shown to have been arbitrary or capricious, since the administrator of the plan had discretionary authority to determine eligibility for benefits. Metropolitan Life Ins. Co. v. Glenn, 128 S. Ct. 2343, 2348 (2008). The issue is not whether this Court agrees with the

administrator's decision, but whether the defendant had a reasonable basis for that decision. Michaels v. Equitable Life The plan

Assur. Soc., 2009 WL 19344 (3d Cir. Jan. 5, 2009).

decision may be overturned only if it is "without reason, unsupported by substantial evidence or erroneous as a matter of law." 1993). The defendant finds support for its decision in such cases as Senkier v. Hartford Life & Accident Ins. Co., 948 F.2d 1050 (7th Cir. 1991)(Posner, J.). The sweeping language of that Abnathya v Hoffman-LaRoche, Inc., 2 F.3d 40-45 (3d Cir.

decision provides support for the decision here, notwithstanding the fact that, in the Senkier case the policy language actually excluded coverage for injuries suffered during medical treatment; and the reasoning of that case has been expressly rejected by the Fourth Circuit Court of Appeals. Whetsell v. Mutual Life Ins.

Co., 669 F.2d 955, 957 (4th Cir. 1982); Griffiths v. Siemens Automotive, LP, 43 F.3d 1466 (4th Cir. 1994). In my view, where

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the courts of appeals are in disagreement on an issue, a decision one way or another cannot be regarded as arbitrary or capricious. Plaintiff's motion for summary judgment will therefore be denied, and defendant's granted. An Order follows.

BY THE COURT:

/s/ John P. Fullam John P. Fullam, Sr. J.

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