2005 D e c i sion s O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit 5-24-2005 

# K elle r v . F or t i s B e nefit s Ins P r e c e de nt i al or N on-P r e c e de nt i al : N on-P r e c e de nt i al D ocke t N o . 03-4214

F o llow thi s and a dd it ion al work s at : http://d i git alc ommon s .l a w . vi ll anova . e du/thir dc ir c uit_2005

Thi s de c i sion i s br ou ght t o you for f r e e and ope n a c c e s s b y the O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit at V i ll anova U nive r sity S choo l of L a

w Di git al Reposit ory

. It h as be e n a c c ept e d for inclusion in 2005 D e c i sion s b y an author i z e d a dmini s tr at or of V i ll anova U nive r sity S choo l of L a

w Di git al Reposit ory

. F or mor e inform at ion, p le as e c ont a ct Be n j amin . C arl s on@l a

w . vi ll anova . e du . Re c omme nde d C it at ion
" Ke lle r v . F or t i s Be nefits In s " (2005). 2005 D e cisio n s . P ape r 1144. http://d i git alc ommon s .l a

w . vi ll anova . e du/thir dc ir c uit_2005/1144NOT P RE CE DE NT I AL UN I TED STATES CO UR T OF A PP EALS F O R T H E T H IR D C IR C U IT

N o. : 03- 4214
AM Y S. KELLER
v. F OR T I S BE NE F I T S I NS UR ANC E CO M P ANY M E T RO P L E X C OR P OR AT I ON L I F E I NS UR ANC E P L AN

F o r t i s B e n e f

i t s I n s u r a n c e C o m p a n y, A ppel l ant

N o. : 03- 4313
A M Y S . K E L L E R , A p p e llan t

v. F OR T I S BE NE F I T S I NS UR ANC E CO M P ANY M E T RO P L E X C OR P OR AT I ON L I F E I NS UR ANC E P L AN

A ppeal fr om U ni t ed St at es D i s t r i ctC our tforthe W e ste rn D istric t o f

P e n n sy lv a n ia ( D . C
. 00- cv- 2368) H onor abl e R ober tJ . C i ndr i ch2 A r gued: J anuary20, 2005 B efor e: A L I T O , M cK E E and SM I T H , C i r cui tJ udges

( O pi ni on Fi l ed M ay24, 2005)
C ouns el forA ppel l ant/ C r os s A ppel l ee J os hua B achr ach R aw l e & H ender s on O n e S o u th P en n S q u are T he W i denerB ui l di ng Phi l adel phi a, PA 19107 C ouns el forA ppel l ee/ C r os s A ppel l ant K athl een Smi t h- D el ach Phi l l i ps & Fal dow s ki 29 E as tB eau Str eet W as hi ngt on, PA 15301
O p inion o f th e C o u rt
M cK E E , C i r cui tJ udge. For t i s B enef

i t s I ns ur ance C om panyappea l s the di s t r i ctcour t ’ s or dergr ant i ng
s um m aryj udgm entagai ns ti tand i n favorof A m yS. K el l er( “K el l er ”) i n t hi s act i on for benef i t s al l egedl ydue undera gr oup acc i dent al death and di s m ember m enti ns ur ance p o licy(“ A D & D ” ) iss u e d b yF o rtis. K e ller c ro ss -a p p e a ls th e c o u rt’s d ism iss a l o f h e r sta teW e nee d notdi s cus s t he di s t r i ctcour t ’ s pr eempt i on rul i ng as the Supr eme C our thas 1 s i n c e d e c i d e d t h a tb a d f a i t h i n s u r a n c e c l a i ms u n d e rs t a t e l a w a r e p r e e mp t e d b yE RI S A, ju s t a s th e d is tr ic t c o u rt ru le d
. See Aetna Heal th, I nc ., v . D a v ila , 1 2 4 S
. C t. 2 4 8 8 (20 0 4 ). O ur r eview of a g rantof sum m aryj ud gm ent i s de novo
. W e a p p lythe s am e stan d ard 2 th a t th e lo w e r c o u rt u s e d
. Sm athers v. Mul t i
- Tool s , I nc. , 2 9 8 F . 3 d 1 9 1 , 1 9 4 (3d C ir
. 2002)
. T he s t andar d of r evi ew w hen det erm i ni ng w hetheran i ns ur ance companythat b o th f u n d s a n d a d m in is te rs th e p la n is a h e ig h te n e d a rb itr a ry a n d c a p ri c io u s re v ie w . P in to v. R el i ance Standar d Li f e I ns . C o. , 2 1 4 F .3 d 3 7 7 , 3 7 8 (3 d C ir. 2 0 0 0 ). T h is s tan d a rd is to a p p lie d o n a s lid in g s c a le , w ith th e le v e l o f s c ru tin yin c re a s in g w ith th e le v e l o f c o n f lic t. I d. a t 3 7 9
. 3 l a w c l a i ms f

o rb a d f a i t h u n d e r4 2 P a . C. S
. § 8 3 7 1
. F o rth e r e a s o n s s e tf o r t h b e l o w, we affirm bo t h o rder s. 1 I. I n a s mu c h a s we a r e wr i t i n g o n l yf o rth e p a r t i e s wh o a r e f a mi l i a rwi t h th i s c a s e , we
n e e d n o t se t f

o rth th e f a c tu a l o r p ro c e d u ra l b a c k g ro u n d e x c e p t in so f a r a s m a yb e h e lp f

u l. R ather , w e w i l l pr ocee d di r ect l yt o ourbr i ef di s cus s i on. 2 F o rtis’ d e n ial le tter s tate d in p a rt: beca us e M r . K el l erw as 6' 3" t al l , ther e had t o have be en a pr eci pi t at i ng event . T her e i s i ns uffi ci entevi dence s uppor t i ng loss o f c o n scio u sn ess d u e to b lun t hea d injury ; ho w ev er, th ere is s u b sta n tial e v id e n c e th a t th e u n c o n sc io u sn e ss , w h ich led to hi s dr ow ni ng, w as caus ed bya s ei zur e. H avi ng s uffe r ed a s ever e hea d i nj ur yi n 1991, K el l erw as atr i s k fordevel opi ng seizu re d isord er. Si nce For t i s bot h admi ni s t er s and funds the pl an ati s s ue her e, w e mustfi r s tdeci de t he appr opr i at e amountof def er ence , i f any , t o aff

or d For t i s ’ deci s i on t o denycover age. For t i s i ni t i al l yappr oved cove r age a nd t hen dec l i ned cove r age. I tr el i ed upon the medi calI n P i nt o v. R el i ance Standar d Li f e I ns . C o. , 2 1 4 F .3 d 3 7 7 , 3 7 9 (3 d C ir . 2 0 0 0 ), we 3 not ed thatone fa ct orcouns el i ng l es s defe r ence w as w hetherthe i ns ur err el i ed upon evi dence t hatw as cons i s t entw i t h i t s deci s i on t o denycover age w hi l e notcr edi t i ng ( w i t houtexpl anat i on) evi dence t hatw oul d s uppor tcover age. 4 expert i s e of tw o doct or s . O ne of them coul d notdet erm i ne the ca us e of de ath and the ot herrul ed i tan “a cci dent , ” butconcl uded thatthe dea t h w as “mostl i kel y ” pr eci pi t at ed b ya g ran d m al seizu re. H o w ev er, othe r ev iden ce su g g ested the u n d erly ing ca u se o f M r. K e ller’ s d ro w n in g c o u ld n o t b e c o n c lu siv e lyd e ter m in e d . In its d e n ial le tter, F o rtis
c re d ited e v id e n c e th a t w a s c o n sis ten t w ith d e n y in g p a ym e n t w ith o u t ex p lain in g w h yit
w as ig n o ri n g ev iden ce that su p p o rt ed co v era g e o r un d erm ined it s co n clus ion that M r. K el l er ’ s death w as notcover ed. A ccor di ngl y , w e bel i eve Fort i s ’ deni al deci s i on i s ent i t l ed t o l es s defe r ence t han w oul d ot herw i s e be the ca s e. 3 A. For t i s fi r s tcl ai m s t hatt he dea t h w as notan ac ci dent , and ther efor e the pol i cydoes noteven a ppl y . I n t he al t ernat i ve, For t i s ar gues thati f the dea t h w as an ac ci dent , and the pol i cydoes appl y , t hen the “di s eas e exc l us i on” pr ecl udes cover age. H ow ever , D r . Sm i th, t he for ens i c pathol ogi s tt o w hom For t i s r efe r r ed the fi l e foran expe r topi ni on, det erm i ned t hatM r . K el l er ’ s death w as “ac ci dent al
. . . due t o dr ow ni ng. ” SA 13. T he i s s ue has not been w hethert he d row ning dea t h w as “acci den t al , ” bu tw hetherthe p reci pit at i ng cause
w as excl uded undert he pol i cy . For t i s poi nt s t o i t s deni al l et t erand r el i es on t he s t at ement t hat : “ther e i s i ns uffi ci entevi dence s uppor t i ng l os s of cons ci ous nes s due t o bl unthead5

i nj ur y . ” H ow ever , t hatdoes notexpl ai n how For t i s coul d r el yonl yupon evi dence
c o n s is te n t w ith d e n y in g K e lle r’ s c la im w h ile ig n o ri n g e v id e n c e th a t s u p p o rt e d c o v e ra g e . A ccor di ngl y , w e agr ee thatFor t i s abus ed i t s di s cr et i on i n det erm i ni ng thatM r . K el l erw as
n o t k ill e d b ya n a c c id e n t. B. W e m u st al so d ec ide w h ethe r F o rt is ab u sed it s d iscreti o n in co n clud ing that M r. K el l er ’ s death fel l w i t hi n t he exc l us i onaryl anguage of i t s pol i cy . T he pol i cypr ovi des t hatno benef

i tw i l l be pai d “i f the l os s r es ul t s di r ect l yfr om . . . anyphy s i cal di s eas e. ” The t erm “phy s i cal di s eas e” i s notdefi ned i n t he pol i cy . For t i s chos e t o appl ythatt erm t o a gr and mal s ei zur e; a one t i m e eve ntthati tcoul d t hen def i ne as a “di s eas e, ” thus t r i gger i ng t he exc l us i on. H ow ever , M r . K el l erhad no hi s t oryof s ei zur es fol l ow i ng the
m edi cal pr ocedur e i n 1991, and ther e i s no evi dence of a l at entdi s eas e. T he di s t r i ctcour texpl ai ned i t s r ej ect i on of For t i s ’ at t empt t o r el yon t he exc l us i on as fol l ow s: T he bes tevi dence For t i s can must eri s thatK el l erm ayhave

e x p e ri e n c e d m u ltip le m ild s e iz u re s a n d n o t e v e n k n o w n it. E ven ac cept i ng D r . Sm i t h’ s anal y s i s . . . ther e i s abs ol ut el yno ev iden ce . . . to co n clud e tha t K ell er su ff ere d fro m a se izure p h y sic a l d ise a se d a tin g f ro m 1 9 9 1 . T h is w a s a n u n u su a l, su d d en an d u n ex p ec ted e v en t. T h e m ere p o tential ityfo r a s e iz u re s o m e tim e in th e f u tu re is n o t a d is e a s e . M emora ndum O r der , Sept
. 23, 2003, p. 8. W e agr ee. C .6

F o r t h e re a s o n s s e t f

o rt h a b o v e , w e w ill a f

f ir m .