All facts, unless otherwise noted, are taken from the Joint 1

Stipulation of Facts signed and submitted by both parties.

IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF PENNSYLVANIA

KRIS RAMABADRAN

v.

THE PRUDENTIAL INSURANCE COMPANY

OF AMERICA

:

:

:

:

:

:

CIVIL ACTION

05-4570

JOYNER, J. August 14, 2006

MEMORANDUM AND ORDER

Via the motion now pending before this Court, Plaintiff

seeks summary judgment. Also before this Court is Defendant’s

cross motion seeking summary judgment and dismissal of

Plaintiff’s claims. For the reasons set forth below, Plaintiff’s

motion is denied, and Defendant’s motion is granted.

I. Background1

Plaintiff filed the instant suit on September 29, 2005, to

recover benefits allegedly due him under an insurance policy. 

Plaintiff, Kris Ramabadran, is employed by Johnson & Johnson

full-time as an Assistant Director of Clinical Pharmacy. Through

Plaintiff’s employment, he was issued Group Policy G-42150, which

provides Accidental Death and Dismemberment Coverage (the

“Policy”). The Policy is funded and administered by Defendant,

The Prudential Insurance Company of America (“Defendant” or

“Prudential”).

Plaintiff’s wife, Rajalakshmi Ramabadran (“Mrs.

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 1 of 14
The Policy provided accidental death benefits in the amount 2

of three times the insured’s annual salary, or $366,000.00 in the

case of Plaintiff’s wife.

Ramabadran”), died on March 24, 2004 as a result of a brainstem

herniation due to subarachnoid hemorrhage. Mrs. Ramabadran was

erroneously given intravenous Heparin, a blood thinner, in place

of a paralytic agent that was to have been administered prior to

a procedure to implant a device to monitor Plaintiff’s brain

bleed. (Admin. Record PRU 0079.)

On April 28, 2004, Prudential received a claim for Dependent

Personal Accidental Death benefits under Group Policy G-42150

from Plaintiff for the death of his wife. On July 7, 2004, 2

Prudential denied Plaintiff’s claim on the basis that a loss is

not covered by the Policy if it is the result – direct or

indirect – of sickness or medical treatment for sickness, and

Prudential believed that the claim fell within this exclusion. 

The Policy provides, in relevant part, that 

[b]enefits for accidental Loss are payable only if all

of these conditions are met:

(1) The person sustains an accidental bodily Injury

while a Covered Person.

(2) The Loss results directly from that Injury and from

no other cause.

(3) The Loss is due to a Covered Accident.

(Admin. Record PRU 000104.) Further, the Policy states that 

[a] Loss is not covered if it results from . . . 

(3) Sickness, whether the Loss results directly or

indirectly from the Sickness.

(4) Medical or surgical treatment of Sickness, whether

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 2 of 14
the Loss results directly or indirectly from the

treatment (except medical or surgical treatment

necessitated solely due to the injury).

(Admin. Record PRU 000105.)

The initial certificate of death listed the manner of death

as “natural.” On November 8, 2004, Plaintiff appealed

Prudential’s initial decision to deny benefits. In support of

this appeal, Plaintiff submitted an amended certificate of death

noting that the manner of death was “accident.” The cause of

death was listed as cerebral aneurysm due to (or as a consequence

of) subarachnoid hemorrhage due to (or as a consequence of)

brainstem herniation. (Admin. Record PRU 0044.) Heparin

toxicity was listed as a significant condition contributing to

death. (Id.)

On December 20, 2004, Prudential upheld its decision to deny

benefits because it determined that Mrs. Ramabadran’s death was a

result of (1) sickness (subarachnoid hemorrhage) and (2) a

medical misadventure (erroneous injection of Heparin), and not

exclusively from an “accidental injury” and no other cause. On

March 21, 2004, Plaintiff again appealed Defendant’s denial of

benefits. On this appeal, Plaintiff contended that the

administration of Heparin was not medical treatment for Mrs.

Ramabadran’s subarachnoid hemorrhage and was, in fact, contrary

to medical treatment of Mrs. Ramabadran’s sickness. On April 5,

2004, Prudential again upheld its denial of benefits, stating

that Mrs. Ramabadran’s death resulted from complications from

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 3 of 14
“her sickness and treatment and not solely from an accidental

injury.”

II. Legal Standard for a Motion for Summary Judgment

In deciding a motion for summary judgment under Fed. R. Civ.

P. 56(c), a court must determine “whether there is a genuine

issue of material fact and, if not, whether the moving party is

entitled to judgment as a matter of law.” Medical Protective Co.

v. Watkins, 198 F.3d 100, 103 (3d Cir. 1999) (citations omitted). 

Rule 56(c) provides that summary judgment is properly rendered: 

. . . if the pleadings, depositions, answers to

interrogatories, and admissions on file, together with

the affidavits, if any, show that there is no genuine

issue as to any material fact and that the moving party

is entitled to a judgment as a matter of law. 

Thus, summary judgment is appropriate only when it is

demonstrated that there is no genuine issue as to any material

fact and that the moving party is entitled to judgment as a

matter of law. Celotex Corp. v. Catrett, 477 U.S. 317, 322-32

(1986). An issue of material fact is said to be genuine “if the

evidence is such that a reasonable jury could return a verdict

for the nonmoving party.” Anderson v. Liberty Lobby, Inc., 477

U.S. 242, 248 (1986).

A party seeking summary judgment bears the initial burden of

identifying portions of the record that demonstrate the absence

of issues of material fact. Celotex, 477 U.S. at 323. The party

opposing a motion for summary judgment cannot rely upon the

allegations of the pleadings, but instead must set forth specific

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 4 of 14
facts showing the existence of a genuine issue for trial. Id. at

324; Fed. R. Civ. P. 56(e).

III. Standard of Review

The parties have stipulated that the Policy is an employee

welfare benefit plan subject to the provisions of the Employee

Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq.

(“ERISA”). Thus, we treat Plaintiff’s claim as seeking relief

under 29 U.S.C. § 1132(a)(1)(b), which allows a beneficiary to

sue for benefits due to him under the terms of the plan.

Under ERISA, a denial of benefits is reviewed de novo,

unless the relevant policy gives the plan administrator

discretionary authority to determine eligibility for benefits. 

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). 

Where such authority is given, the administrator’s decision will

be overturned where it is arbitrary and capricious. Orvosh v.

Program of Group Ins. for Salaried Employees of Volkswagen of

Am., Inc., 222 F.3d 123, 129 (3d Cir. 2000). An administrator’s

decision is arbitrary and capricious where it is “‘clearly not

supported by the evidence in the record or the administrator has

failed to comply with the procedures required by the plan.’” Id.

(quoting Abnathya v. Hoffman-LaRoche, Inc., 2 F.3d 40, 41 (3d

cir. 1993)).

Where, however, a single entity both funds and administers a

policy, a heightened form of the arbitrary and capricious

standard applies. Pinto v. Reliance Standard Life Ins. Co., 214

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 5 of 14
F.3d 377, 378 (3d Cir. 2000). This heightened standard of review

is based on a sliding scale approach so that the intensity of the

scrutiny matches the degree of conflict of interest. Id. at 379. 

In determining the appropriate standard of review, courts look to

factors such as the sophistication of the parties and any

“suspicious events” or “procedural anomalies” during the claims

process. Id.; see also Stratton v. E.I. DuPont de Nemours & Co.,

363 F.3d 250, 254 (3d Cir. 2004).

Here, the Policy provides that

[t]he Prudential Insurance Company of America as Claims

Administrator has the sole discretion to interpret the

terms of the Group Contract, to make factual findings,

and to determine benefits payable. The decision of the

Claims Administrator shall not be overturned unless

arbitrary and capricious. 

(Joint Stip. of Facts ¶ 15.) Prudential admits that it both

administers and funds the Policy. (Id.) The parties have

stipulated that a heightened arbitrary and capricious standard is

applicable. (Id. ¶ 16.)

Prudential argues that there is no evidence of procedural

bias or anomaly, and the lowest level of heightened scrutiny is,

therefore, appropriate. While it is not entirely clear which

party bears the burden of showing the appropriateness of

heightened scrutiny, we find no indication of the type of

procedural irregularities and inequities found in Pinto and other

such cases, and Plaintiff has alleged none. See Pinto, 214 F.3d

at 386 (distinguishing Kotrosits v. GATX Corp. Non-contributory

Pension Plan for Salaried Employees, 970 F.2d 1165, 1173 (3d Cir.

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 6 of 14
In referring to the aneurysm in this discussion, we include 3

both the cerebral aneurysm and subarachnoid hemorrhage.

1992)). It appears that Prudential followed the procedures set

out in the Policy, and was consistent in its findings and

interpretations. Thus, we will apply a low level of heightened

scrutiny that gives the fiduciary decision "some deference, but

[such] deference will be lessened to the degree necessary to

neutralize any untoward influence resulting from the conflict.” 

Stratton, 363 F.3d at 256 (quoting Doe v. Group Hospitalization &

Med. Servs., 3 F.3d 80, 87 (4th Cir. 1993)).

IV. Discussion

We consider both motions for summary judgment together

because the parties disagree on the answers to the same three

questions: (1) was the aneurysm a “sickness” or an “injury”; (2) 3

was the erroneous dose of Heparin “treatment” of the aneurysm;

and (3) was death the result of an accidental bodily injury and

no other cause? We examine whether any genuine issue of material

fact remains as to these inquiries.

A. Was the aneurysm a “sickness” or an “injury”?

The Policy clearly states that a loss resulting directly or

indirectly from sickness or treatment for sickness is not

eligible for benefits. (See Admin. Record PRU 000105.) The

Policy defines sickness as “[a]ny disorder of the body or mind of

a Covered Person, but not an Injury; pregnancy of a Covered

Person, including abortion, miscarriage or childbirth.” (Admin.

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 7 of 14
The agreement in Gatti was not analyzed under the ERISA 4

framework.

Record PRU 000121.) The Policy defines an injury as “injury to

the body of a Covered Person.” (Id.)

Defendant argues that it reasonably concluded, based on the

information presented, that Mrs. Ramabadran’s aneurysm was a

sickness within the meaning of the Policy. Plaintiff contends

that an aneurysm is an injury. We consider whether either of

these arguments successfully shows that there is no genuine issue

of material fact as to this question.

In support of his argument that an aneurysm is an injury

under the Policy, Plaintiff asserts that we must view the term

“in the broadest light most favorable to [Plaintiff].” (Pl.’s

Mem. at 9.) Plaintiff relies on Gatti v. Hanover Ins. Co., 601

F. Supp. 210, 211 (E.D. Pa. 1985) for the proposition that an

insurance policy is to be viewed in its entirety, and its terms

given their ordinary and plain meaning. (See Pl.’s Mem. at 6-7.) 

That same mandate requires that even in construing the language

of the agreement in the light most favorable to a plaintiff, we

must consider its other provisions. Plaintiff cannot, by 4

focusing solely on the meaning of “injury,” to the exclusion of

all other provisions, show that no genuine issue of material fact

exists as to whether Mrs. Ramabadran’s aneurysm was an injury. 

Such an analysis makes the exclusionary provisions of the

agreement meaningless.

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 8 of 14
We note that other courts have concluded that a 5

subarachnoid aneurysm, unless caused by an accidental bodily

injury (e.g. head trauma), is generally considered to result from

some form of disease. Fruge v. First Continental Life and

Accident Ins. Co., 430 So. 2d 1072, 1075 (La. App. 1983)

(citations omitted).

Nor can Plaintiff show, merely by alleging ambiguity in a

term of the Policy, that Defendant made its decision in a manner

inconsistent with the Policy or the facts. Plaintiff relies

entirely on his allegations, and presents no evidence in support

of his contention that an aneurysm must be an injury under the

plan. Such reliance is patently insufficient to support summary

judgment to Plaintiff’s benefit. See supra Part II.

Defendant argues that Mrs. Ramabadran’s aneurysm and

resulting hemorrhage amount to a “sickness” under the Policy. 

Defendant submits that an aneurysm is a condition that generally

occurs as a result of disease. (Def.’s Mem. at 9 (citing Medline 5

Plus).) Defendant also argues that Plaintiff has admitted that

Mrs. Ramabadran suffered from a sickness. Plaintiff’s counsel,

by way of a letter of March 21, 2005 addressed to the Director of

Defendant’s Group Life Claim Division, acknowledged the exclusion

for treatment of sickness, but argued that the administration of

Heparin was not “treatment” because it was “completely contrary

to medical treatment of Mrs. Ramabadran’s sickness.” (Admin.

Record PRU 0032 (emphasis added).) Dr. MacBride, who initially

reviewed the medical records relating to Mrs. Ramabadran’s death,

likewise concluded that the aneurysm and hemorrhage were a

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 9 of 14
The Policy provides that any loss resulting directly or 6

indirectly from sickness is excluded. Plaintiff has not argued,

nor do we believe he could credibly argue, that, if the aneurysm

is a sickness, that Mrs. Ramabadran’s death resulted therefrom,

at least indirectly.

sickness, not an injury. (Admin. Record PRU 0055.)

Plaintiff presents no evidence in contradiction of this

conclusion. Plaintiff, having failed to directly respond to

Defendant’s motion, apparently relies on his argument that an

aneurysm is an injury. Even if Defendant, as Plaintiff argues,

bears a burden to prove that an exclusion applies, Plaintiff must

still point to some evidence in support of its claim. (See supra

Part II.) Plaintiff has, therefore, failed to show that any

genuine issue of material fact exists as to whether Mrs.

Ramabadran’s aneurysm is a “sickness” under the Policy.

B. Was the erroneous dose of Heparin “treatment” of the

aneurysm?

While the conclusion that no material question of fact

remains as to whether the aneurysm was a sickness can, itself,

sustain summary judgment, we consider the other arguments relied 6

upon by Plaintiff and rejected by Defendant in making the

eligibility determination. Plaintiff argues that providing an

incorrect drug cannot be “treatment” of a sickness. 

Specifically, Plaintiff alleges that the term “treatment of

sickness” is ambiguous, and that any ambiguity must be resolved

in his favor.

Even assuming that this language is ambiguous, in an ERISA

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 10 of 14
We need not determine whether the language is actually 7

ambiguous.

analysis, ambiguities are not automatically resolved in a

plaintiff’s favor. Rather, “[i]f the reviewing court determines

the terms of a plan document are ambiguous, it must take the

additional step and analyze whether the plan administrator's

interpretation of the document is reasonable.” Bill Gray Enters.

v. Gourley, 248 F.3d 206, 218 (3d Cir. 2001) (citing Spacek v.

Maritime Ass'n ILA Pension Plan, 134 F.3d 283, 292 (5th Cir.

1998)). Thus, the question before us is whether Defendant’s

conclusion that “treatment of sickness” includes improper or

mistaken treatment is reasonable.7

Defendant argues that while Pennsylvania courts have not

addressed whether medical mistakes and malpractice can be

included in “treatment,” other courts have so found. Numerous

courts have considered the question of whether similar clauses

exclude coverage for death caused by medical mistakes in the

course of treatment for a condition that would not otherwise give

rise to an eligible loss. See Whetsell v. The Mutual Life Ins.

Co. of NY, 669 F.2d 955 (4th Cir. 1982); Swisher-Sherman v.

Provident Life & Accident Ins. Co., 1994 U.S. App. LEXIS 28768

(6th Cir. 1994); Reid v. Aetna Life Ins. Co., 440 F. Supp. 1182

(S.D. Ill. 1977), aff’d 588 F.2d 835 (7th Cir. 1978). While we

need not determine whether these courts were correct, we cannot

conclude that Defendant’s decision is unreasonable in light of

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 11 of 14
the varied authority supporting this decision. Plaintiff offers

no argument or authority that this interpretation is

unreasonable, but instead relies on the broad assumption that the

terms of the contract must be broadly construed in his favor. In

the absence of some evidence or authority to the contrary, we can

adduce no genuine issue of material fact as to whether Defendant

could reasonably interpret “treatment of sickness” to include

medical mishaps.

C. Was death the result of an accidental bodily injury and

no other cause?

To be covered by the Policy, a loss must be the result of an

accidental bodily injury and no other cause. Plaintiff argues

that the medical mistake in administering Heparin was a separate,

intervening accidental bodily injury. Plaintiff relies on

Whetsell’s definition of accident. (Pl.’s Mem. at 7.) Even if

the medical mishap can be considered an accidental bodily injury,

Plaintiff must still show that the loss was the result of such

injury and no other cause. (See Admin. Record PRU 000104.) 

The death certificate as the stipulated facts, show that

there is no genuine issue of material fact as to whether cerebral

aneurysm and subarachnoid hemorrhage were among the causes of

Mrs. Ramabadran’s death. (Admin. Record PRU 0044; Joint Stip. of

Facts ¶ 3.) Furthermore, to the extent that Plaintiff argues

that the medical mishap creates a separate loss, the same cases

including medical mistakes in “treatment” also reject the

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 12 of 14
contention that a medical mistake for an underlying ineligible

condition creates a new injury. See Whetsell, 669 F.2d at 956;

Reid, 440 F. Supp. at 1183; Swisher-Sherman, 1994 U.S. App. LEXIS

28768. Thus, Plaintiff cannot show that Mrs. Ramabadran’s death

resulted from accidental injury and no other cause.

For the reasons set forth above, Plaintiff’s motion for

summary judgment is denied, and Defendant’s motion for summary

judgment is granted. An appropriate order follows.

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 13 of 14
IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF PENNSYLVANIA

KRIS RAMABADRAN

v.

THE PRUDENTIAL INSURANCE COMPANY

OF AMERICA

:

:

:

:

:

:

CIVIL ACTION

05-4570

ORDER

AND NOW, this 14 day of August, 2006, upon consideration th

of Plaintiff’s Motion for Summary Judgment (Doc No. 13), and

Defendant’s response thereto (Doc. No. 17), Defendant’s Cross

Motion for Summary Judgment (Doc. Nos. 14, 15), and the Statement

of Stipulated Facts in Support of Cross Motions for Summary

Judgment (Doc. No. 13), it is hereby ORDERED that Plaintiff’s

motion is DENIED and Defendant’s motion is GRANTED.

BY THE COURT:

s/J. Curtis Joyner 

J. CURTIS JOYNER, J.

Case 2:05-cv-04570-JCJ Document 18 Filed 08/15/06 Page 14 of 14