Court Opinion

ID: 4656880
Source: CourtListenerOpinion
Date Created: 2021-02-03 02:00:31.564352+00
Date Added: 2024-06-11T08:01:04.871351
License: Public Domain

Case: 20-40302     Document: 00515729811         Page: 1     Date Filed: 02/02/2021

              United States Court of Appeals
                   for the Fifth Circuit                               United States Court of Appeals
                                                                                Fifth Circuit

                                                                              FILED
                                                                        February 2, 2021
                                  No. 20-40302                           Lyle W. Cayce
                                                                              Clerk

   Sonya E. Byerly, Independent Executor of the Estate of
   Gregory G. Byerly,

                                                           Plaintiff—Appellant,

                                       versus

   Standard Insurance Company,

                                                           Defendant—Appellee.

                  Appeal from the United States District Court
                       for the Eastern District of Texas
                            USDC No. 4:18-CV-592

   Before Jolly, Southwick, and Costa, Circuit Judges.
   Per Curiam:*
          Gregory Byerly stubbed his toe in a household accident. Due to
   several preexisting medical conditions—diabetes, peripheral neuropathy,
   and peripheral arterial disease—the injury eventually required a below-the-
   knee amputation of his leg. He filed a claim under his employer-sponsored

          *
            Pursuant to 5th Circuit Rule 47.5, the court has determined that this
   opinion should not be published and is not precedent except under the limited
   circumstances set forth in 5th Circuit Rule 47.5.4.
Case: 20-40302      Document: 00515729811           Page: 2    Date Filed: 02/02/2021

                                     No. 20-40302

   accidental death and dismemberment (AD&D) plan. The plan administrator
   rejected the claim on the ground it was not just the stubbing of his toe, but
   also his preexisting conditions, that resulted in the need for an amputation.
   Byerly’s wife then brought this ERISA suit on behalf of his estate (Byerly
   passed away for reasons unrelated to the amputation). Concluding that there
   was no qualifying “loss” even under de novo review of the claim, we
   AFFIRM.
                                          I.
          Byerly worked in Texas for Fidelity National Information Services,
   Inc. when he stubbed his toe. Fidelity provided its employees an AD&D
   Group Policy issued by Standard Insurance Company.
          The Policy provides benefits under the following conditions:
          If you have an accident, including accidental exposure to
          adverse conditions, while insured for AD&D Insurance, and
          the accident results in a Loss, we will pay benefits according to
          the terms of the Group Policy after we receive Proof Of Loss
          satisfactory to us.
   The Policy covers the loss of a foot, so long as the loss meets all the following
   requirements:
          1. Is caused solely and directly by an accident.
          2. Occurs independently of all other causes.
          3. With respect to Loss of life, is evidenced by a certified copy
          of the death certificate.
          4. With respect to all other Losses, occurs within 365 days after
          the accident and is certified by a Physician in the appropriate
          specialty as determined by us.
          The Policy then excludes certain accidental losses. AD&D benefits
   are not payable “if the accident or loss is caused or contributed to by . . .
   [s]ickness . . . existing at the time of the accident” and sickness is defined as
   “your sickness, illness, or disease.”

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                                     No. 20-40302

          Doctors who treated Byerly after he stubbed his toe noted the
   contribution of his preexisting conditions to the pain in his toe. The doctor
   Byerly visited three days after the accident diagnosed him with a toe wound
   with secondary cellulitis and uncontrolled Type 1 diabetes mellitus with
   peripheral neuropathy. A podiatrist diagnosed Byerly with a “diabetic foot
   ulcer associated with diabetes mellitus due to underlying condition, with
   necrosis of bone.” The surgeon who amputated the leg recorded that Byerly
   “recently was admitted with a nonhealing left heel decubitus related to his
   neuropathy and peripheral arterial disease.”
           The doctors whom Standard asked to review the case reached similar
   conclusions. Dr. Bergstrom concluded that “the development of infection
   and gangrene was related to his current medical conditions (diabetes,
   peripheral neuropathy, and [peripheral artery disease]), and likely would not
   have occurred in the absence of those conditions.” Dr. Fancher, who looked
   at the case after Byerly appealed the initial claim denial, found that Byerly did
   “not require an amputation due to trauma alone,” concluding it “could have
   only happen[ed] if he had severe underlying vascular disease, which clearly
   was the case here.” In his opinion, Byerly’s “nonhealing ulcer, with
   gangrene, and his need for amputation was directly related to his diabetes and
   to his severe peripheral vascular disease.” Out of the hundreds of patients
   Dr. Fancher has seen for foot injuries, he had “never encountered an
   otherwise health[y] patient who required an amputated leg, from a simple
   ‘stubbed toe,’ or from any other minor foot injury or laceration.” But, he
   noted, “[t]he sequence of events that happened [to Byerly] is extraordinarily
   common . . . in diabetics with vascular disease.”
          Based on these opinions, Standard denied Byerly’s claim. It found
   that the amputation was caused, at least in part, by his diabetes and peripheral
   vascular disease. As a result, his loss “did not fall within the Group Policy’s
   insuring clause” because it “was not caused solely and directly by an
   accident, independently of all other causes.” It also found that the exclusion
   applied because Byerly’s sickness contributed to the loss.
          This lawsuit followed. The district court issued a 46-page ruling
   granting summary judgment to Standard. It spent much of its analysis

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                                    No. 20-40302

   discussing what standard of review applied. Although it ultimately decided
   that deference was owed to the plan administrator’s determination, it also
   held that it would affirm the denial of benefits even under de novo review.
                                         II.
          As we are reviewing this case at the summary judgment stage, we owe
   no deference to the district court’s view of the case. Schexnayder v. Hartford
   Life & Accident Ins. Co., 600 F.3d 465, 468 (5th Cir. 2010). But the parties
   disagree about the underlying standard of review when a federal court
   reviews the decision of an ERISA plan administrator.
          The Policy grants discretion to the administrator: “Except for those
   functions which the Group Policy specifically reserves to the Policyholder,
   we have full and exclusive authority to control and manage the Group Policy,
   to administer claims, and to interpret the Group Policy and resolve all
   questions arising in the administration, interpretation, and application of the
   Group Policy.” Ordinarily, that would mean we review only for abuse of
   discretion. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
          Plaintiff argues, however, there are two reasons why that deference is
   not warranted. First, she contends that the law of Texas, where her husband
   lived when he worked for Fidelity, applies rather than the law of Florida,
   where Fidelity was based. That choice-of-law question might affect the
   standard of review because Texas bans delegation clauses in insurance
   policies, whereas Florida does not. See TEX. INS. CODE § 1701.062(a); Nat’l
   Ass’n of Ins. Comm’rs, Prohibition on the Use of Discretionary Clauses Model
   Act ST-42-3–6 (2020), https://content.naic.org/sites/default/files/inline-
   files/MDL-042.pdf (not listing Florida among the 26 states that ban
   delegation clauses); see also Ariana M. v. Humana Health Plan of Tex., Inc.,
   884 F.3d 246, 256–57 (5th Cir. 2018) (en banc) (holding that de novo review
   applies when a state law validly bars delegation clauses). Even if the Texas
   antidelegation statute does not apply, Plaintiff argues that our deference to a
   plan’s discretion is lessened because of the conflict of interest when, as here,

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                                           No. 20-40302

   the plan administrator also pays the benefits.1 See Metropolitan Life Ins. Co.
   v. Glenn, 554 U.S. 105, 115–17 (2008).
           But we need not wade into those issues. Even assuming arguendo that
   the best possible standard for the Plaintiff—de novo review—applies, we
   would not disagree with the claim denial. Covington v. Aban Offshore Ltd.,
   650 F.3d 556, 558–59 (5th Cir. 2011) (providing that a choice of law analysis
   is unnecessary when the application of two bodies of law leads to the same
   result).
           On the merits, Plaintiff does not dispute that Byerly’s comorbidities
   substantially contributed to his amputation. Indeed, three separate doctors,
   including Byerly’s own treating provider, stated that the gangrene and
   osteomyelitis that led to the amputation would not have happened but for his
   diabetes, peripheral neuropathy, and peripheral arterial disease. That would
   seem to settle the issue: Byerly’s “loss” was not caused “solely and directly
   by an accident” nor did it “occur independently of all other causes.”
   Byerly’s underlying medical conditions, not just the accident (stubbing the
   toe), contributed to the amputation.2
           Although she does not dispute the consensus medical view that
   Byerly’s preexisting conditions contributed to the need for an amputation,
   Plaintiff argues that looking at what caused the amputation is asking the
   wrong question. She contends that the focus instead should be on what
   caused the “initial injury” to the toe. That would help her because the
   preexisting conditions did not cause Byerly to stub his toe; stubbing the toe
   was an accident. The problem for Plaintiff is that the Policy places the focus

           1
              This conflict-of-interest claim may be forfeited because it was not raised below.
   See, e.g., Caples v. U.S. Foodservice, Inc., 444 F. App’x 49, 54 n.4 (5th Cir. 2011) (declining
   to consider an administrator conflict-of-interest argument because it was not presented to
   the district court).
           2
             For the same reason, the “sickness” exclusion also likely applies, but we need not
   get to that exclusion as we find no coverage in the first place.

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                                     No. 20-40302

   not on the cause of the accident or initial injury but on the cause of the “loss.”
   The loss is the amputation, so the amputation must be “caused solely and
   directly by an accident” and must “[o]ccur[] independently of all other
   causes.” Because neither of those two conditions are met here, the Policy
   does not provide coverage.
                                         ***
          We AFFIRM the judgment of the district court.

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