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Saladin v. Prudential Insurance Co. of America

February 26, 2008

RITA SALADIN, PLAINTIFF,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, DEFENDANT.



The opinion of the court was delivered by: Hon. Norman A. Mordue, Chief U.S. District Judge

MEMORANDUM-DECISION AND ORDER

INTRODUCTION

Plaintiff moves (Dkt. No. 8) for summary judgment in this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., to recover a $100,000 accidental death benefit under a group insurance policy issued by defendant to plaintiff's late husband. Defendant cross-moves for summary judgment (Dkt. No. 11). For the reasons set forth below, the Court denies plaintiff's motion, grants defendant's cross-motion, and dismisses the complaint without prejudice.

FACTS

The undisputed facts are as follows. Defendant Prudential Insurance Company of America issued a Group Accidental Death and Dismemberment Insurance Policy ("policy") to J.C. Penney Corp. Plaintiff's husband, Albert Saladin, an employee of J.C. Penney Corp. until July 31, 1994, participated in the policy and named plaintiff as the primary beneficiary.

On May 28, 2004, Mr. Saladin fell in the bathroom of his home, hitting the right side of his head. He was admitted to the hospital the following day. After a diagnosis of a right subdural hematoma, he underwent a right frontal craniotomy with evacuation of the hematoma. A subsequent CAT scan revealed a left cerebral hemorrhage with herniation. He died on June 4, 2004. The death certificate states the "immediate cause" of death as "subdural hematoma/cerebellar hemorrhage," "due to or as a consequence of parkinsonism/dementia."

By letter dated August 16, 2004, plaintiff's attorney, John N. Kalil, Esq., submitted plaintiff's claim for benefits under the policy. By letter dated September 17, 2004, defendant disclaimed coverage based on an exclusion in the policy. The disclaimer stated that, upon reviewing the insured's death certificate, the medical records from his final hospitalization, and the group policy booklet, defendant concluded as follows:

Since Mr. Saladin's death resulted from complications of his sickness, not from an accidental injury, the death does not meet the group policy's definition of accidental death. Furthermore, the death certificate indicates that the insured died of natural causes. Since the cause and manner of death did not meet the group policy's definition of accidental death, we are denying your claim for accidental death benefits in the amount of $100,000.

The portion of the policy booklet cited by defendant in denying coverage states that accidental death benefits are payable when the insured sustains "an accidental bodily injury" and "The Loss results directly from that injury and from no other cause." The policy excludes loss resulting from "Sickness, whether the loss results directly or indirectly from the Sickness."*fn1

The disclaimer letter also informed plaintiff of her right to appeal the decision, and gave substantial information regarding the appeal process. It included the following:

You have a right to appeal this decision. If you elect to do so, your appeal must be made in writing by you or your authorized representative.... Your appeal should contain:

* The reasons that you disagree with our determination

* The name, policy number and claim number for the insured

* Medical evidence or documentation to support your position Evidence or documentation may include but not be ...


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