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GUISTI v. GENERAL ELEC. CO.

March 15, 1990

ADELIA GUISTI, PLAINTIFF,
v.
GENERAL ELECTRIC COMPANY AND THE TRAVELERS INSURANCE COMPANY, DEFENDANTS.



The opinion of the court was delivered by: McCURN, Chief Judge.

MEMORANDUM — DECISION AND ORDER

Introduction

This is an action for the recovery of accidental death benefits under an insurance policy issued by The Travelers Insurance Company ("Travelers") to the General Electric Company ("GE") for the benefit of GE's employees. The plaintiff, Adelia Guisti, is the widow of Raymond Guisti, a GE employee who died on November 28, 1988. It is not disputed that the decedent was covered by the policy at the time of his death and that his wife was the named beneficiary. Mrs. Guisti has brought suit against GE and The Travelers on the assertion that she has been wrongfully denied $50,000 in accidental death benefits due under the terms of the policy. The defendants contend that under the facts of this case and the terms of the policy Mrs. Guisti is not entitled to receive benefits.

Plaintiff initially filed this suit as a state law claim in the Supreme Court of the State of New York, Montgomery County. The defendants subsequently removed the action to federal court on the basis that the cause of action was preempted by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. On January 2, 1990, the court filed an order denying plaintiff's motion to remand on the basis that the action is one for the collection of benefits due under an ERISA covered employee benefit plan — federal question jurisdiction being based upon 29 U.S.C. § 1132(e). Though not originally framed as an ERISA action, the parties now agree that the plaintiff's claim for benefits must be considered as an action pursuant to 29 U.S.C. § 1132(a)(1)(B). "That provision allows a suit to recover benefits due under the plan, to enforce rights under the terms of the plan, and to obtain a declaratory judgment of future entitlement to benefits under the provisions of the plan contract." Firestone Tire and Rubber Co. v. Bruch, ___ U.S. ___, 109 S.Ct. 948, 953, 103 L.Ed.2d 80 (1989). Presently before the court are cross motions for summary judgment. The parties have not engaged in discovery.

Background

Most of the facts are not in dispute. On November 19, 1988, Mr. Guisti, along with four friends, traveled to a hunting lodge located in Cherry Valley, New York. The group spent the night at the cabin as they were planning to begin hunting the next day. The cabin was equipped with a propane gas refrigerator that apparently leaked carbon monoxide. The following morning Mr. Guisti awoke with a headache, nausea and vomiting, chest pain and shortness of breath. The other members of the group also had headaches, nausea, and vomiting but they apparently did not have chest pains. While Mr. Guisti remained ill, the symptoms of the others cleared. Mr. Guisti's companions took him to a store in Cherry Valley and called an ambulance which transported him to Mary Imogene Bassett Hospital in Cooperstown, N Y

Mr. Guisti spent eight days in the hospital before his death due to heart failure on the morning of November 28, 1988. The key issue presented in this suit is whether Mr. Guisti's death was an accidental death of the sort which is covered by the terms of the insurance policy. There is a dispute over the precise cause of Mr. Guisti's death. As will be discussed more thoroughly below, the defendants assert that he died, at least in part, due to an "underlying coronary artery disease." The plaintiff claims that the death was a result of damage to the heart muscle tissue caused by carbon monoxide poisoning. No autopsy was performed.

The parties both focus on two portions of "The Travelers/General Electric Personal Accident Insurance Plan for Accidental Death and Dismemberment (As Amended June 27, 1988)." The first portion, which discusses the scope of coverage afforded by the plan states:

  Benefits will be paid for bodily injury, either
  on or off the job, caused solely by accidental,
  violent and external means, and, independently of
  all other causes, resulting in death. . . . [N]o
  benefits will be payable if the death or loss is
  contributed to by disease . . .

The parties are in dispute as to whether this clause excludes from coverage the type of death suffered by Mr. Guisti. The second policy provision, which discusses the responsibility of The Travelers to administer and manage claims under the plan states:

  The carrier will make all determinations with
  respect to benefits under this Plan. Accordingly,
  the management and control of the operation and
  administration of claim procedures under the
  Plan, including the review and payment or denial
  of claims and the provision for full and fair
  review of claim denial pursuant to Section 503 of
  [ERISA], shall be vested in the carrier.

As will be discussed, the defendants assert that this provision provides The Travelers with discretionary authority to make determinations on claims which may only be overturned by a reviewing court if they are "arbitrary and capricious."

As the named beneficiary to Mr. Guisti's accidental death insurance policy, the plaintiff filed a claim with GE for $50,000 in benefits allegedly due under the policy in May of 1989. Along with the insurance claim the plaintiff forwarded to GE copies of the medical records from Mr. Guisti's hospitalization. These documents were transferred to The Travelers's claim department who in turn forwarded the file to Dr. Gerald Blank M.D. of The Travelers medical staff. Dr. Blank was also provided with a copy of the "relevant policy language" and asked for his opinion as to whether Mr. Guisti's death was covered by the terms of the policy. After reviewing the hospital record Dr. Blank concluded that:

  There is no doubt that this unfortunate gentleman
  died of his Myocardial Infarction which resulted
  directly from the hypoxia of carbonmonoxide
  poisoning. However, as stated in the discharge
  summary "Carbon monoxide poisoning in the face of
  underlying coronary artery disease."
  Under section 1 of the Personal Accident
  Insurance Plan it states "no benefits will be
  payable if the death or loss is caused or
  contributed to by disease, . . .". In my opinion
  this death comes under this exclusionary
  statement. The statement of the discharging
  physician would support that opinion.

Memorandum of Gerald I. Blank M.D., Exhibit F of the 2/1/90 Affidavit of Lawrence C. Fox ("Fox Affidavit"). In a letter dated June 27, 1989, The Travelers denied the plaintiff's claim for accidental death benefits on the basis that the "insured's death was caused or contributed to by [underlying coronary artery] disease." Letter of Eva Magnano, Exhibit G of the Fox Affidavit. However, the letter recognized that the heart failure "resulted directly from the hypoxia of carbon monoxide poisoning." Id. The letter also informed the plaintiff of her ability to appeal the claim within 60 days by submitting any additional ...


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