United States District Court, Southern District of New York
April 15, 1991
CATHERINE ARTHURS, PLAINTIFF,
METROPOLITAN LIFE INSURANCE COMPANY AND THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, DEFENDANTS.
The opinion of the court was delivered by: Sweet, District Judge.
Defendant Metropolitan Life Insurance Company
("Metropolitan") has moved for summary judgment dismissing the
complaint of plaintiff Catherine Arthurs ("Arthurs"). For the
following reasons, the motion is denied.
Arthurs is the widow of Raymond Arthurs, who was, at the time
of his death, employed as a splicer by the Consolidated Edison
Company of New York, Inc. ("Con Ed"). Mr. Arthurs died on June
17, 1986, following his collapse while working in a Con Ed
"vault" at the Port Authority Terminal in New York City.
Metropolitan is an insurance company licensed to do business
in New York. Metropolitan insures a Group Life Insurance Plan
("the Plan") provided by Con Ed to its employees. Mr. Arthurs
was covered by the Plan at the time of his death.
Prudential Insurance Company of America ("Prudential"), not
a party to the present motion, is also an insurance company
licensed to do business in New York. Prudential insured Mr.
Arthurs under two individual life insurance policies.
Following her husband's death, Arthurs sought to collect on
his life insurance policies and also filed a claim for workers'
compensation. Over objection from Con Ed, the Workers'
Compensation Board granted her claim, finding that Mr. Arthurs
"would not have died . . . if he had not been working in a hot
closed vault." The Board therefore concluded that he had
"sustained an accident arising out of and in the course of his
employment and the subsequent death was causally related."
Both insurance companies paid Arthurs the basic death
benefits due to her, but refused to pay the additional
accidental death benefits called for under the policies.
Arthurs therefore sued the insurers in New York State Supreme
Court in May 1990 for breach of the insurance contracts.
Metropolitan removed the case to this Court pursuant to
28 U.S.C. § 1441(c), asserting that because Arthurs' claim against
it related to an employee benefit plan governed by the Employee
Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001-1461,
federal question jurisdiction existed.
On December 5, 1990, Metropolitan moved for summary judgment
dismissing the complaint. Oral argument on the motion was heard
on January 14, 1991.
The Summary Plan Description dated July 1984 ("the Summary"),
which was distributed to covered Con Ed employees pursuant to
ERISA, 29 U.S.C. § 1022, states
In addition to any other benefits which you may
receive, [accidental death or dismemberment]
benefits will be paid for bodily injury sustained
on or off the job while insured for this coverage
and caused solely through violent, external and
accidental means which results in death or the loss
of hand, foot, or sight or eye.
Benefits are paid when the death or loss takes
place within 90 days after the injury and is not
caused in whole or in part from disease, bodily or
mental infirmity, hernia, insurrection,
intentionally self-inflicted injury, or any act of
Summary at 4 (emphasis added).
Both parties appear to agree that Mr. Arthurs died as a
result of a heart attack. Arthurs claims that the attack was
brought on by his working for several hours in the enclosed
vault where the temperature exceeded 110 degrees, while
Metropolitan argues that a pre-existing disease or bodily
infirmity, namely coronary arteriosclerosis, was at least
partially responsible for the collapse and death, which excuses
it from paying the accidental death benefits.
Mr. Arthurs' death certificate contains the following
a. Immediate cause:
Occlusive coronary arteriosclerosis.
b. Due to or as a consequence of:
Pending further study.
His autopsy report states "Coronary arteries exhibit moderate
arteriosclerosis. There is a 50 to 60% stenosis of the anterior
descending branch of the left coronary artery." The report
concludes that the cause of death was occlusive coronary
arteriosclerosis, and states that it was "natural."
In the proceedings before the Workers' Compensation Board,
Con Ed relied on the opinion of Dr. Nathaniel E. Reich
("Reich"), who examined the medical file, including the death
certificate and autopsy report and concluded that "It is
apparent that [Mr. Arthurs] dies as a result of the natural and
spontaneous progression of the coronary artery disease and his
work had no effect upon his condition. . . ." Dec. 5, 1990
Affidavit of Christine Rowlands ("Rowlands Aff.") Exhibit F at
9. Arthurs' own medical expert was Dr. Seymour S. Cutler
("Cutler"), who concurred with the medical examiner's finding
that the cause of death was occlusive coronary
arteriosclerosis, and stated "I believe that superimposed upon
this pre-existing occlusive disease, the strenuous work
activities precipitated a sudden cardiac arrhythmia which
1. Arthurs Has Stated a Claim for Relief Under ERISA.
Metropolitan seeks to dismiss Arthurs' state law claim for
breach of the
insurance contract as preempted by ERISA. While the preemption
analysis is correct, the appropriate remedy is not to dismiss
of the claim but rather to treat it as a claim made under
ERISA. 29 U.S.C. § 1132(a)(1)(B).*fn1
See, e.g., Guisti v.
General Electric Co., 733 F. Supp. 141
, 145 (N.D. N.Y. 1990)
(treating removed state law claim as properly stating claim
under ERISA); Howard v. Gleason Corp., 716 F. Supp. 740
(W.D.N.Y. 1989) (preemption requires denial of motion to remand
to state court, not dismissal of state law claim), aff'd,
901 F.2d 1154
(2d Cir. 1990).
2. Metropolitan's Denial of Accidental Death Benefits Must be
Reviewed De Novo.
Metropolitan asserts that its determination that Arthurs is
not entitled to accidental death benefits must be reviewed
under an "arbitrary and capricious" standard, while Arthurs
claims that a de novo review is called for. In Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101
, 109 S.Ct. 948, 103 L.Ed.2d
80 (1989), the Supreme Court held that a claim for denial of
benefits under 29 U.S.C. § 1132(a)(1)(B) should generally be
reviewed de novo. However, in those cases in which the plan
administrator had been granted discretionary authority to
determine eligibility for benefits and to construe the terms of
the plan, the more deferential "arbitrary and capricious"
standard was appropriate. 489 U.S. at 110-15, 109 S.Ct. at
953-56. Although the Court did not explicitly deal with the
standard of proof required, its use of the de novo standard as
the default, together with its citation of ERISA's purpose "to
promote the interests of employees and their beneficiaries" and
"to protect contractually defined benefits," 489 U.S. at 113,
109 S.Ct. at 955 (quoting Shaw v. Delta Air Lines, Inc.,
463 U.S. 85
, 90, 103 S.Ct. 2890, 2896, 77 L.Ed.2d 490 (1983) and
Massachusetts Mutual Life Ins. Co. v. Russell, 473 U.S. 134
148, 105 S.Ct. 3085, 3093, 87 L.Ed.2d 96 (1985)), implies that
in order to qualify for the more deferential standard, a plan
administrator bears the burden of establishing that it does
wield discretionary authority over benefits decisions. See Moon
v. American Home Assurance Co., 888 F.2d 86
, 88-89 (11th Cir.
1989); Baxter v. Lynn, 886 F.2d 182
, 187 (8th Cir. 1989); Brown
v. Ampco-Pittsburgh Corp., 876 F.2d 546
, 550 (6th Cir. 1989).
In making this determination, any ambiguities must be construed
against the administrator and in favor of the party seeking
judicial review, particularly in a situation (such as the
present one) where the plan administrator is also the party
responsible for paying the benefits at issue. Guisti, supra,
733 F. Supp. at 141; cf. Firestone, 489 U.S. at 115, 109 S.Ct.
at 956 (conflict of interest of plan administrator may be
relevant to determining whether abuse of discretion exists).
Metropolitan has not pointed to any language in the Summary
to supports its position. The portion of the Summary cited in
support of its claim to discretionary authority reads
How to File Claims
All claim forms needed to file for benefits under
the Group Insurance program can be obtained from
Benefits Planning and Administration, Room 947-S,
4 Irving Place, who will also be ready to answer
questions about the insurance benefits and to
assist in filing claims.
The completed claim form should be returned to
Benefits Planning and Administration, who will
certify coverage under the plan and will then
forward the claim form to the Metropolitan Life
If any benefits are denied a written explanation
will be provided.
Summary at 6. Nothing in this section grants Metropolitan
discretionary authority to rule on eligibility for benefits. On
the other hand, the section cited earlier providing for
accidental death benefits states that such benefits "will be
paid," with no reqirement
that Metropolitan must agree to the payment. See Heidgerd v.
Olin Corp., 906 F.2d 903
, 908 (2d Cir. 1990) (no grant of
discretion where plan summary provided "you will receive
severance" and "benefits are payable") (emphasis in Heidgerd).
Metropolitan has supported its claim to discretionary
authority by referring to the review process by which it
handled Arthurs' claim, which it asserts is the typical way in
which such claims are handled. However, this purported review
process merely consisted of denying the claim and informing
Arthurs that she had a right to appeal the decision to
Metropolitan, a right which Arthurs declined to exercise,
choosing to file suit instead. Metropolitan has offered no
evidence that this "review process" is authorized by or even
contemplated by the Plan itself.*fn2
The section of the Summary identified as "Statement of ERISA
Rights" states: "If you have a claim for benefits which is
denied or ignored, in whole or in part, you may file suit in a
state or federal court." This statement fails to imply any
discretion in Metropolitan's payment of benefits.
Therefore, Metropolitan's denial of accidental death benefits
must be analyzed under a de novo standard of review.
3. There Are Factual Disputes Which Preclude Summary Judgment.
A. Standard for summary judgment
The standards for summary judgment are well-known. The court
is not "to weigh the evidence and determine the truth of the
matter but to determine whether there is a genuine issue for
trial." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106
S.Ct. 2505, 2511, 91 L.Ed.2d 202 (1986).
By its very terms, this standard provides that the
mere existence of some alleged factual dispute
between the parties will not defeat an otherwise
properly supported motion for summary judgment; the
requirement is that there be no genuine issue of
As to materiality, the substantive law will
identify which facts are material. Only disputes
over facts that might affect the outcome of the
suit under the governing law will properly
preclude the entry of summary judgment. Factual
disputes that are irrelevant or unnecessary will
not be counted.
Id., 477 U.S. at 247-48, 106 S.Ct. at 2509-10 (emphasis in
In a case such as the present one, in which some factual
disputes exist, the first step is to identify the substantive
law governing the case, then to determine whether any of the
disputed facts is material.
B. Applicable law
"Given [the] language and history [of ERISA,] we have held
that courts are to develop a `federal common law of rights and
obligations under ERISA-regulated plans.'" Firestone, 489 U.S.
at 110, 109 S.Ct. at 954 (quoting Pilot Life Ins. Co. v.
Dedeaux, 481 U.S. 41, 56, 107 S.Ct. 1549, 1557, 95 L.Ed.2d 39
(1987)). Metropolitan's denial of accidental death benefits to
Arthurs must be reviewed under principles of this federal
Although the questions presented here — what constitutes an
accident for the purposes of a double indemnity clause and
whether a pre-existing health condition should prevent an
insured from recovering accidental death benefits — have for
years been the subject of litigation in numerous state courts,
see, e.g., Graves v. Travelers Ins. Co., 66 Wis.2d 124,
224 N.W.2d 398 (1974); Salisbury v. John Hancock Mutual Life Ins.
Co., 259 Or. 453, 486 P.2d 1279 (1971); Slobojan v. Western
Travelers Life Ins. Co., 70 Cal.2d 432, 74 Cal.Rptr. 895,
450 P.2d 271 (1969) (in bank); Mutual Life Ins. Co. of New York v.
Smith, 248 Miss. 448, 160 So.2d 203 (1964); Brown v.
Metropolitan Life Ins. Co., 327 S.W.2d 252 (Mo. 1959) (en
banc); Silverstein v. Metropolitan Life Ins. Co., 254 N.Y. 81,
171 N.E. 914 (1930) (all awarding accidental death benefits);
Metropolitan Life Ins. Co. v. Smith, 554 S.W.2d 123 (Tenn.
1977); Merrick v. Metropolitan Life Ins. Co., 88 Nev. 327,
497 P.2d 890 (1972); Union Central Life Ins. Co. v. Scott, 286 Ala. 10,
236 So.2d 328 (1970); Neeman v. John Hancock Mutual Life
Ins. Co., 182 Neb. 144, 153 N.W.2d 448 (1967); Horn v.
Protective Life Ins. Co., 265 N.C. 157, 143 S.E.2d 70 (1965);
Jackson v. Southland Life Ins. Co., 239 Ark. 576,
393 S.W.2d 233 (1965); Venable v. Aetna Life Ins. Co., 174 Ohio St. 366,
189 N.E.2d 138 (1963); Pan American Life Ins. Co. v. Andrews,
161 Tex. 391, 340 S.W.2d 787 (1960); Miller v. Prudential Ins.
Co., 183 Kan. 667, 331 P.2d 310 (1958); Prudential Ins. Co. v.
Kellar, 213 Ga. 453, 99 S.E.2d 823 (1957); Berg v. New York
Life Ins. Co., 88 So.2d 915 (Fla. 1956); Bergeron v. Prudential
Ins. Co., 96 N.H. 304, 75 A.2d 709 (1950) (all denying
benefits), there are few cases dealing with the issues under
federal common law. In Adkins v. Reliance Standard Life Ins.
Co., 917 F.2d 794, 796 (4th Cir. 1990), the court commented
Promoting the interests of employees and the
beneficiaries does not seem to us to mean, as is
so frequently said, that the purpose of
legislation is corrective and it must be liberally
construed in favor of the beneficiary. The
[Firestone] Court could have said just that if it
desired. . . . Just as importantly, however, we do
not feel that [the Court's] language calls for an
overly literal compliance with those decisions most
favorable to a finding [against the claimant].
After all, as at least some of the authority has
noted, in order to recover under such policies as
the one here involved, and with such a stringent
construction, a claimant would have to be in
perfect health at the time of his most recent
injury before the policy would benefit him, and
that, of course, is a condition hardly obtained,
however devoutly to be wished.
After analyzing the various possible interpretations, the court
We think a better solution is to take a middle
ground as has been taken by Kentucky in
Colonial Life & Accident Ins. Co. v. Weartz,
636 S.W.2d 891 (Ky. Ct. App. 1982). . . . It [stated]
the rule in such cases as follows:
[A] pre-existing infirmity or disease is not to
be considered as a cause unless it substantially
contributed to the disability or loss. . . . [A]
"pre-disposition" or "susceptibility" to injury,
whether it results from congenital weakness or
from previous illness or injury, does not
necessarily amount to a substantial contributing
cause. A mere "relationship" of undetermined
degree is not enough.
636 S.W.2d at 894. . . . We think [this rule]
gives effect to the [Firestone] Court's admonition
to promote the interests of the employees and
beneficiaries in employee benefit plans.
Id. at 797 (citing Firestone, 489 U.S. at 110-14, 109 S.Ct. at
953-56). Similarly, in Guisti, supra, the court stated that
"not every disease or medical condition which hypothetically
contributes to a death is considered a disease which `causes or
contributes' to a death for the purposes of making an ERISA
benefits determination." 733 F. Supp. at 149.
The rule to be applied, therefore, is similar to that
enunciated by the New York Court of Appeals in Silverstein,
"If there is no active disease, but merely a frail
general condition, so that powers of resistance
are easily overcome, or merely a tendency to
disease which is started up and made operative,
whereby death results, then there may be recovery
even though the accident would not have caused
that effect upon a healthy person in a normal
254 N.Y. at 85, 171 N.E. at 914 (quoting from Leland v. Order
of United Comm. Travelers of Amer., 233 Mass. 558, 564,
124 N.E. 517, 520 (1919)).
C. Application to the present dispute
In view of the foregoing discussion, there are factual
disputes which preclude summary judgment.*fn3 Arthurs has
some evidence to show that her husband's fatal heart attack was
brought on by the extremely high temperature in the confined
space of the vault, and that those conditions were not the
usual conditions under which he was expected to work. More
significantly, Metropolitan — the moving party — has failed
to offer any evidence to establish that the phrase "occlusive
coronary arteriosclerosis" as used in both the autopsy report
and the death certificate necessarily signifies that Mr.
Arthurs' death was in fact due to a pre-existing disease or
bodily infirmity. While the term "arteriosclerosis" may be
familiar to many people in this day and age, a court cannot
simply apply its own layperson's interpretation of the
condition when the term is used by a medical expert in the
context of a professional opinion. See also McNamee v.
Metropolitan Life Ins. Co., 137 N.J.L. 709, 61 A.2d 271 (1948)
(death certificate reference to "cardiac disease" of doubtful
weight where physician who signed certificate had no knowledge
of decedent or circumstances surrounding death). Thus,
Metropolitan has not met its burden of showing the absence of a
triable issue of fact concerning the relationship, if any,
between Mr. Arthurs' possible heart condition and his death.
Under Firestone and its progeny, Metropolitan's denial of
accidental death benefits to Arthurs must be reviewed de novo.
Because a genuine issue of material fact exists, Metropolitan's
motion for summary judgment is denied.
It is so ordered.