Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-16-01861/USCOURTS-ca7-16-01861-0/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
Cause of Action: 

---

In the 

United States Court of Appeals 

For the Seventh Circuit ____________________ 

No. 16-1861 

LEE ANN PRATHER, 

Plaintiff-Appellant, 

v.

SUN LIFE AND HEALTH INSURANCE COMPANY (U.S.), 

Defendant-Appellee. 

____________________ 

Appeal from the United States District Court for the 

Central District of Illinois. 

No. 3:14-cv-03273 — Richard Mills, Judge. 

____________________ 

ARGUED NOVEMBER 2, 2016 — DECIDED DECEMBER 13, 2016 

____________________ 

Before WOOD, Chief Judge, and POSNER and WILLIAMS, 

Circuit Judges. 

POSNER, Circuit Judge. The plaintiff’s decedent, Jeremy 

Prather, was employed by a company that had obtained a 

Group Insurance Policy from Sun Life which provided accidental death and dismemberment coverage for the company’s employees, in the amount of $92,000 for Prather. The 

policy limited coverage to “bodily injuries ... that result directly from an accident and independently of all other causes.” 

Case: 16-1861 Document: 33 Filed: 12/13/2016 Pages: 6
2 No. 16-1861 

The clause we’ve italicized is the focus of this appeal from 

the district court, which granted summary judgment for Sun 

Life, which had invoked the clause to deny the payment of 

death and dismemberment coverage to Prather’s survivor on 

the ground that his death had not been the exclusive result 

of an accident—it had also been the result of “complications 

from surgical treatment.” Prather’s widow brought this suit 

“to recover benefits due to [her]” under the plan. 29 U.S.C. § 

1132(a)(1). 

On July 16, 2013, Prather, age 31, had torn his left Achilles tendon playing basketball. Three days later he met with 

an orthopedic surgeon to discuss treatment, and of the options offered he chose surgery. He was scheduled to be operated on three days later, July 22. On July 21 he called the 

surgeon’s office complaining of a swelling in the lower part 

of his left leg, and that an area of the left calf was both sensitive and warm to the touch. The surgeon told him to elevate 

the leg. The surgery next day to repair his torn Achilles tendon was uneventful and he was discharged from the hospital the same day. He returned to work and was reported as 

doing well in a follow-up visit to his surgeon on August 2. 

But four days later he collapsed at work, went into cardiopulmonary arrest, and died the same day as a result of a 

deep vein thrombosis (blood clot) in the injured leg that had 

broken loose and traveled through the bloodstream to a 

lung, thus becoming a blood clot in the lung—that is, a pulmonary embolism—which caused cardiac arrest and sudden 

death. 

Sun Life’s position is that the pulmonary embolism and 

ensuing death were consequences not of—at least not entirely of—the accident to Prather’s Achilles tendon, but of the 

Case: 16-1861 Document: 33 Filed: 12/13/2016 Pages: 6
No. 16-1861 3 

surgery. Of course that means it was also a consequence of 

the accident, for without the accident there would have been 

no surgery. But it may have been a consequence of the surgery as well. Indeed it is even possible that had it not been 

for the surgery, Prather would not have died. 

A physician’s assistant employed by Sun Life opined in a 

“Death Review Claim,” prepared by her as part of Sun Life’s 

review of Prather’s claim, that deep vein thrombosis and 

pulmonary embolism are risks of surgery, but that even with 

conservative treatment, such as immobilization of the affected limb, the insured had an enhanced risk of a blood clot. 

That was Sun Life’s only medical evidence, however, and it 

was inconclusive. It was evidence not that Prather’s death 

was a result not just of the accident but also of independent 

events—namely the surgery but maybe also or instead the 

immobilization of his leg before surgery—but that it might

have been a partial result of such events—partial because the 

accident had to have played a role; no accident, no surgery or 

immobilization, hence no deep vein thrombosis or pulmonary embolism.

Although the insurance contract purports to place the entire burden of proof on the insurance beneficiary—it says the 

death must have occurred “independently of all other causes,” which Sun Life interprets to require the beneficiary to 

disprove any possible alternative cause of death—that can‘t 

be right because it would give the insurer carte blanche to 

reject coverage in a case in which an accident is a conceded 

cause of death (there is no suggestion that Prather, a young 

man, would be dead had he not torn his Achilles tendon), 

merely because there is some speculative possibility that 

something else may also have played a role. That would 

Case: 16-1861 Document: 33 Filed: 12/13/2016 Pages: 6
4 No. 16-1861 

make many accident insurance contracts vacuous, illusory, 

because often there is an interval between the accident and a 

resulting injury, and a possibility that something in that interval caused or aggravated the insured’s injury. Since the 

accident alone—the rupturing of the tendon—may well have 

caused the blood clot that killed Prather, the insurance company had to present some evidence that the surgery had been 

a cause of Prather’s death—and it presented none. All it 

“proved” through the physician’s assistant was that the surgery might have been a cause of Prather’s death; no effort 

was made to quantify the added risk created by the surgery. 

The forensic pathologist who conducted a post-mortem 

examination of Prather did not attribute his death to the surgery, and the relevant medical literature indicates that there 

is a significant incidence of deep vein thrombosis (the final 

trigger of the pulmonary embolism) following the rupture of 

an Achilles tendon even if the tendon is not operated on. 

Deep venous [vein] thrombosis (DVT) is a significant source of morbidity and mortality and is associated with many orthopedic procedures. Previous 

studies have reported highly variable DVT rates in 

patients with Achilles tendon rupture undergoing 

operative and nonoperative treatment. We performed 

a retrospective chart review for all patients who 

underwent Achilles tendon repair at our institution 

from January 2006 to February 2012. Patient data 

were collected from the electronic medical record 

system. A total of 115 patients were eligible for the 

present study. Of these patients, 27 (23.47%) with a 

surgically treated Achilles tendon rupture developed a symptomatic DVT either while waiting for, or 

after, surgical intervention, with approximately one 

third of these diagnosed before surgical intervention. ... 

Case: 16-1861 Document: 33 Filed: 12/13/2016 Pages: 6
No. 16-1861 5 

We have shown a high incidence of DVT after 

Achilles tendon rupture. We recommend a high 

level of suspicion for the signs and symptoms of 

DVT during the follow-up period. 

Makhdom AM (Asim M.) et al., “Incidence of Symptomatic 

Deep Venous Thrombosis After Achilles Tendon Rupture,” 

52 Journal of Foot & Ankle Surgery 584 (2013) (emphases added). 

Sun Life argues unpersuasively that its insurance contract with Prather’s employer gave Sun Life “discretion to 

decide what evidence was sufficient to demonstrate a disability.” But that would amount to the insurer’s having carte 

blanche to decide whether or not to honor its contract. The 

company also argues, again unpersuasively, that “the evidence in this matter makes clear that Mr. Prather’s surgical 

treatment contributed to his death[,] ... indeed, caused the 

forming of a blood clot in Mr. Prather’s deep veins.” No, the 

evidence does not make that clear. All the evidence shows is 

that his death followed both the surgery and the accident 

that preceded the surgery. Post hoc is not propter hoc. And we 

know from the medical literature that an accident alone can 

create a fatal blood clot and so far as appears could have 

done so in this case. 

Indeed, Prather’s complaint the day before the surgery of 

a swelling in the lower part of his left leg and that an area of 

the left calf was sensitive and warm to the touch suggests 

that the deep vein thrombosis might have formed by then, 

because swelling, pain, and warmth in the affected limb 

were all symptoms of DVT. Because Sun Life failed to make 

any plausible showing that the surgery on Prather’s ankle, 

rather than the accident that necessitated the surgery, caused 

Case: 16-1861 Document: 33 Filed: 12/13/2016 Pages: 6
6 No. 16-1861 

his death, the judgment in favor of the defendant is reversed 

and the district court is instructed to enter judgment in favor 

of the plaintiff. See Senkier v. Hartford Life & Accident Ins. Co., 

948 F.2d 1050, 1052 (7th Cir. 1991).

Case: 16-1861 Document: 33 Filed: 12/13/2016 Pages: 6