Court Opinion

ID: 4676838
Source: CourtListenerOpinion
Date Created: 2021-04-13 18:00:30.379389+00
Date Added: 2024-06-11T08:03:34.814109
License: Public Domain

Case: 20-20165        Document: 00515819666        Page: 1   Date Filed: 04/13/2021

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

                                                                              FILED
                                                                          April 13, 2021
                                    No. 20-20165                         Lyle W. Cayce
                                                                              Clerk

   Luis Lebron,

                                             Plaintiff—Appellant Cross-Appellee,

                                        versus

   National Union Fire Insurance Company of Pittsburgh,
   Pennsylvania; AIG Claims, Incorporated;

                                         Defendants—Appellees Cross-Appellants.

                     Appeal from the United States District Court
                         for the Southern District of Texas
                              USDC No. 4:18-CV-3935

   Before Jones, Clement, and Graves, Circuit Judges.
   Per Curiam:*
             Plaintiff-appellant Luis Lebron appeals a district court’s judgment
   upholding a denial of benefits under an accidental death insurance policy. We
   affirm.

             *
            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   opinion should not be published and is not precedent except under the limited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: 20-20165     Document: 00515819666           Page: 2   Date Filed: 04/13/2021

                                    No. 20-20165

                                         I.
          Luis worked as a mechanic for The Boeing Company when he
   purchased an accidental death insurance policy (the “Policy”) for himself
   and his wife, Barbara, through Boeing’s benefits plan. The Policy excludes
   coverage for death caused “in whole or in part” by “[i]llness, sickness,
   disease, bodily or mental infirmity, medical or surgical treatment (unless
   treating a covered injury), or bacterial or viral infection, regardless of how
   contracted (except when bacterial infection results from an accidental cut or
   wound or accidental food poisoning).” The plan delegates authority to
   defendant and cross-appellant National Union Fire Insurance Company of
   Pittsburgh, Pennsylvania (“NUFIC”) to determine benefit eligibility as the
   plan administrator. The Policy “is governed by the laws of Washington” to
   the extent not preempted by the Employee Retirement Income Security Act
   of 1974 (“ERISA”).
          Barbara was later diagnosed with end-stage renal disease associated
   with hypertensive cardiovascular disease, which required her to undergo
   regular dialysis treatment. To facilitate her treatment, doctors placed a
   dialysis catheter near her groin. Because Barbara had problems with blood
   clotting during her dialysis treatment, she was prescribed Warfarin, a blood
   thinner.
          On December 11, 2017, Barbara died unexpectedly when she
   accidentally cut her dialysis catheter with scissors while changing a bandage
   around the catheter, causing her to bleed to death. Investigators ruled her
   death an accident; the medical examiner described the circumstances of
   Barbara’s death as “indicative of the decedent inadvertently cutting across
   the ports of her inguinal dialysis catheter while attempting to change
   bandaging.” The medical examiner concluded that Barbara’s death was
   caused by “exsanguination from cut dialysis catheter placed for treatment of

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   end-stage renal disease associated with hypertensive cardiovascular
   disease.”
          Luis claimed benefits under the Policy and later submitted Barbara’s
   death certificate. NUFIC concluded that Luis’ claim was not covered under
   the Policy, in part because Barbara’s death was at least partially caused by
   medical treatment. Luis appealed the denial and submitted the medical
   examiner’s report and letters from two doctors, including one who had
   treated Barbara, stating that Barbara’s death was an accident not attributable
   to “an expected medical complication.” NUFIC’s appeals board upheld the
   denial of benefits “because [Barbara’s] injury did not result directly and
   independently of all other causes in her death.” Lebron then sued NUFIC in
   district court, alleging ERISA violations.
          Before the district court, the parties filed cross-motions for summary
   judgment on the administrative record. The district court referred the matter
   to a magistrate judge, who recommended upholding the denial of benefits.
   The magistrate judge reviewed the denial de novo but concluded that Luis
   was not entitled to benefits because Barbara’s “changing of her bandage falls
   within the meaning of medical treatment in this Circuit, and [because] the
   accidental cutting of her inguinal catheter was associated with that medical
   treatment.” All parties objected to the magistrate judge’s recommended
   disposition: Luis objected to the merits conclusion, while the defendants
   objected to the magistrate judge’s de novo review. The district court adopted
   the magistrate judge’s recommended disposition in full, and this appeal and
   cross-appeal timely followed.
                                         II.
          “Standard summary judgment rules control in ERISA cases.”
   Ramirez v. United of Omaha Life Ins. Co., 872 F.3d 721, 725 (5th Cir. 2017)
   (citations omitted). De novo review is the “default” standard of review
   applicable to both factual and legal bases of ERISA benefits decisions unless

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   an ERISA plan contains a valid, lawful delegation of discretionary authority,
   in which case the decision is reviewed for abuse of discretion. Ariana M. v.
   Humana Health Plan of Tex., Inc., 884 F.3d 246, 248 (5th Cir. 2018) (en banc).
   Although NUFIC cross-appeals—contesting the magistrate judge’s decision
   that the Policy’s discretionary clause is invalid under Texas law 1 and arguing
   that de novo review applies—we decline to address this issue because Luis’
   argument fails under both de novo review and abuse-of-discretion review.
                                            III.
          The parties do not dispute that Barbara’s death resulted from an
   accident and therefore would be covered but for the “medical or surgical
   treatment” exclusion. Accordingly, the issue is whether Barbara’s actions in
   changing a bandage around her dialysis catheter constitute “medical or
   surgical treatment,” which the Policy excludes from coverage. The Policy
   does not define “medical or surgical treatment.”
          “Federal common law governs rights and obligations stemming from
   ERISA-regulated plans, including the interpretation” of the Policy provision
   at issue here. Provident Life & Accident Ins. Co. v. Sharpless, 364 F.3d 634, 641
   (5th Cir. 2004). See Green v. Life Ins. Co. of N. Am., 754 F.3d 324, 331 (5th
   Cir. 2014). We may also apply analogous state law when such guidance is
   consistent with congressional policy concerns. See Green, 754 F.3d at 331 n.5.
   “When construing ERISA plan provisions, courts are to give the language of
   an insurance contract its ordinary and generally accepted meaning if such a
   meaning exists.” Sharpless, 364 F.3d at 641. We “interpret the contract
   language in an ordinary and popular sense as would a person of average
   intelligence and experience, such that the language is given its generally
   accepted meaning if there is one.” Wegner v. Standard Ins. Co., 129 F.3d 814,

          1
            Texas Insurance Code § 1701.062 bans insurers’ use of discretionary clauses in
   Texas. See Rittinger v. Healthy All. Ins. Co., 914 F.3d 952, 955 (5th Cir. 2018).

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   818 (5th Cir. 1997) (internal quotation marks omitted). “Only if the plan
   terms remain ambiguous after applying ordinary principles of contract
   interpretation are we compelled to apply the rule of contra proferentum and
   construe the terms strictly in favor of the insured.” Id. “An insurance
   contract is ambiguous if it is susceptible to two or more reasonable
   interpretations that can fairly be made,” thus supporting contradictory
   results. Dahl-Eimers v. Mut. of Omaha Life Ins. Co., 986 F.2d 1379, 1381 (11th
   Cir. 1993).
          The term “medical treatment” is unambiguous and has a generally
   accepted meaning, which we are bound to apply. Wegner, 129 F.3d at 818.
   Webster’s Third New International Dictionary defines “medical treatment”
   as “the action or manner of treating a patient medically or surgically,” and
   to “treat” is “to care for (as a patient or part of the body) medically.”
   WEBSTER’S THIRD NEW INTERNATIONAL DICTIONARY 2435 (3d ed. 2002).
   The word “treatment” thus is a “broad term covering all the steps taken to
   affect a cure of an injury or disease; including examination and diagnosis as
   well as application of remedies.” BLACK’S LAW DICTIONARY 1502 (6th ed.
   1990). Barbara’s actions in changing the bandages around her dialysis
   catheter fall under this broad term because, by changing her bandages in
   preparation for a dialysis appointment scheduled later that day, she was
   facilitating treatment for her disease.
          Luis argues that the term “medical or surgical treatment” is
   nonetheless ambiguous because it is normally understood to encompass what
   a doctor or healthcare provider does to a patient, rather than covering what a
   patient does to herself. But in Barkerding v. Aetna Life Insurance Company, 82
   F.2d 358 (5th Cir. 1936), this court defined “medical or surgical treatment”
   to include “the things done by the patient to carry out specific directions
   given for these ends by a physician.” Id. at 359. Therefore, under our caselaw,
   the phrase does not turn on who is providing the treatment. Although Luis

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   argues that Barkerding is distinguishable because there is no evidence that her
   doctors instructed her to change her catheter bandages, the record reflects
   that it was not uncommon for Barbara to change bandages to better facilitate
   dialysis. Further, Barkerding and the exclusionary term’s plain meaning
   dictate that, to be covered under the policy, the accident must result
   independently of medical treatment. That is not the case here. Barbara’s
   tragic death is directly attributable to her medical treatment; she would not
   have died from exsanguination had her illness not necessitated treatment via
   a catheter and bandages to keep the catheter intact. Barbara’s actions in
   changing the bandages around her catheter to prepare for dialysis treatment
   thus amount to “steps taken to affect a cure of” her renal disease, BLACK’S
   LAW DICTIONARY at 1502, and therefore her death was caused at least “in
   part by” medical treatment.
          Moreover, courts uniformly apply the “medical treatment” exclusion
   where an accidental “mishap in the course of treatment” causes death
   because “the normal understanding” is that “injuries caused not by the
   illness itself but by the treatment of the illness” are excluded under policies
   similar to the one at issue in this case. Senkier v. Hartford Life & Accident Ins.
   Co., 948 F.2d 1050, 1052-54 (7th Cir. 1991) (no coverage where patient
   suffering from Crohn’s Disease had a catheter implanted, which later
   inexplicably shifted to puncture the patient’s heart, causing death). See, e.g.,
   Anderson-Tully Co. v. Pan Am. Life Ins. Co., No. 96-5348, 1997 WL 359079, at
   *1 (6th Cir. 1997) (unpublished) (no coverage where patient fell from hospital
   bed, dislodging arterial sheath and causing death); Whetsell v. Mut. Life Ins.
   Co. of N.Y., 669 F.2d 955, 957 (4th Cir. 1982) (no coverage where death was
   caused by accidental use of contaminated IV to administer antibiotics). Cases
   in which a patient overdoses on prescribed medication or in which the
   insured is injured by a doctor’s malpractice are analogous, and in those cases
   courts also uniformly conclude that the mishaps are caused by medical

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   treatment and, therefore, are excluded from coverage. See, e.g., Cady v.
   Hartford Life & Accidental Ins. Co., 930 F. Supp. 2d 1216, 1228 (D. Idaho
   2013) (insured’s overdose on medication prescribed to treat mental illness
   not covered because it fell under policy exclusion for injury caused indirectly
   by medical treatment); Wilson v. Bus. Men’s Assurance Co., 181 F.2d 88, 89
   (9th Cir. 1950) (medical treatment extended to drug prescribed for treating
   insured’s ailment); Pickard v. Transamerica Occidental Life Ins. Co., 663 F.
   Supp. 126, 127 (E.D. Mich. 1987) (death due to drinking wrong solution in
   preparation for colonoscopy was medical treatment under accidental death
   policy); Reid v. Aetna Life Ins. Co., 440 F. Supp. 1182, 1183–84 (S.D. Ill. 1977)
   (accidental injection of lethal drug considered death caused by medical and
   surgical treatment). “It appears that every court that has considered similar
   exclusionary clauses has held such provisions to exclude from coverage death
   caused by various mishaps occurring during the course of medical
   treatment.” Whetsell, 669 F.2d at 956 & n.1 (gathering numerous supporting
   cases).
             Because the term “medical or surgical treatment” unambiguously
   covers Barbara’s actions in changing her bandages in preparation for an
   upcoming dialysis treatment, there is no genuine issue of material fact that
   the Policy does not cover Barbara’s death. We therefore AFFIRM the
   district court’s judgment below.

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