Harris v. Lincoln Nat'l Life Ins. Co.

365 F.Supp.3d 1208

Alexander J. HARRIS, Plaintiff,

v.LINCOLN NATIONAL LIFE INSURANCE CO., Defendant.

Case No.: 5:16-cv-1493-LCB

United States District Court, N.D. Alabama, Northeastern Division.

Signed February 7, 2019

Filed February 8, 2019

Glen M. Connor, Richard P. Rouco, Quinn Connor Weaver Davies & Rouco LLP, Birmingham, AL, for Plaintiff.

Ann P. Hill, Jason A. Walters, Bradley Arant Boult Cummings LLP, Birmingham, AL, for Defendant.

MEMORANDUM OPINION AND ORDER

LILES C. BURKE, UNITED STATES DISTRICT JUDGE

This matter comes before the Court on Defendant Lincoln National Life Insurance Co.'s ("Lincoln") and Plaintiff Alexander Harris's cross motions for Summary Judgment. (respectively Doc. 40, & 28), and Lincoln's former motion for summary judgment (Doc. 12) which has now been superseded. This action involves an employer provided insurance policy and is subject to the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001, et seq. ("ERISA").

Mr. Harris broke his leg and his leg later became infected, would not heal and had to be amputated. He filed a claim under two group accidental dismemberment insurance policies issued by Lincoln. The policies cover accidental dismemberment and exclude coverage where disease was a contributing cause of the loss. Lincoln denied the claim asserting that Mr. Harris's injury resulted from a bone disease brought on by previous radiation treatment he had undergone to treat cancer.

Mr. Harris filed a two count Complaint against Lincoln including: (i) a claim for dismemberment benefits; and (ii) a claim asserting wrongful withholding of documents related to Lincoln's denial of the dismemberment claim. Both Lincoln and Mr. Harris have each separately moved for summary judgment on both claims. (respectively, Doc. 40, & 28.) Lincoln's recently filed reformatted motion (Doc. 40), replaces its previously filed motion (Doc. 12).

For the reasons stated below, Lincoln's Motion for Summary Judgment (Doc. 12) is due to be DENIED as superseded, Lincoln's Reformatted Motion for Summary Judgment (Doc. 40) is due to be GRANTED, and Mr. Harris's Motion for Summary Judgment (Doc. 28) is due to be DENIED .

I. FACTUAL BACKGROUND

A. The Relevant Insurance Policies

On January 1, 2014, Lincoln issued two insurance policies to Mr. Harris's employer, QinetiQ North America, Inc. ("QinetiQ"). AR 000018, AR 000105.¹ The policies included one identified as "Group Insurance Policy No. 00001018133 Providing Life Insurance Accidental Death and Dismemberment Insurance Dependent Life Insurance," AR 000018, which described itself as providing "Basic Life and AD & D Insurance" (the "Basic Policy"), AR 000023. The other policy is titled "Group Insurance Policy No. GL 000403002643 Providing Voluntary Accidental Death and Dismemberment Insurance" (the "Voluntary Policy"). AR 000111.

The Basic Policy provides a dismemberment benefit for accidental injuries. AR 000065. The Basic Policy, however, excludes coverage of those losses that resulted from other contributing causes including disease. AR 000065. The Basic Policy provides in relevant part:

DEATH OR DISMEMBERMENT BENEFIT FOR AN INSURED PER SON.

The Company will pay the benefit listed below if:

(1) an Insured Person sustains an accidental bodily injury while insured under this provision; and

(2) that injury directly causes one of the following losses within 365 days after the date of the accident.

The loss must result directly from the injury and from no other causes.

...

LIMITATIONS.Benefits are not payable for any loss to which a contributing cause is:

...

(2) disease, bodily or mental infirmity, or medical or surgical treatment of disease.

AR 000065 (underlined emphasis added).

Similarly, the Voluntary Policy provides a dismemberment benefit for accidental injuries. AR 000130. The Voluntary Policy also excludes coverage of those losses that resulted from other contributing causes including disease. AR 000137. The Voluntary Policy provides in relevant part:

DEATH OR DISMEMBERMENT BENEFIT FOR AN INSURED PERSON. The Company will pay the benefit listed below if:

(1) an Insured Person sustains an accidental bodily injury while insured under this provision; and

(2) that injury directly causes one of the following losses within 365 days after the date of the accident.

The loss must result directly from the injury and from no other causes.

...

EXCLUSIONS.No benefit will be paid for loss resulting from:

...

(6) sickness, disease or bodily infirmity; except for:

(a) a bacterial infection resulting from an accidental cut or wound ; or

(b) the accidental ingestion of a poisonous food substance; ....

AR 000130, AR 000137 (underlined emphasis added). The Basic Policy and the Voluntary Policy (collectively, the "Policies") both provided that an insured could recover "1/2 Principal Sum" for the "Loss of One Member" which included the loss of a foot. AR 000065; AR 000130.

The claim procedures for both Policies are included in the respective policy document. See AR 000062; AR 000143. Both Policies provide that: "Written notice of an ... dismemberment claim must be given within 20 days after the loss occurs; or as soon as reasonably possible after that." AR 000062; AR 000143. Once a claim is received, Lincoln was obligated to send a claims form to the claimant so that he could submit the requisite proof of loss. Id. The claimant then submits to Lincoln proof of his claim including information that shall "state the nature, date and cause of the loss." Id. In addition to the returning the claim, the claimant is required to include other materials that Lincoln "may reasonably require in support of the claim." Id.

The Policies, in a section titled, "Company's Discretionary Authority," grant Lincoln the authority to determine a claimant's entitlement to benefit:

COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions that this Policy clearly reserves to the Group Policyholder or Employer, the Company has authority to:

(1) manage this Policy and administer claims under it; and

(2) interpret the provisions and resolve questions arising under this Policy.

The Company's authority includes (but is not limited to) the right to:

(1) establish and enforce procedures for administering this Policy and claims under it;

(2) determine Employees' eligibility for insurance and entitlement to benefits;

(3) determine what information the Company reasonably requires to make such decisions; and

(4) resolve all matters when a claim review is requested.

AR 000064; AR 000145. The Polices require Lincoln to send the claimant written notice of its decision, and, in case of a denial, Lincoln is required to explain "the reason for the denial ...;" "how the claimant may request a review of the Company's decision;" and "whether more information is needed to support the claim." AR 000063; AR 000144.

In the Summary Plan Descriptions for each plan, the Policies designate QinetiQ as the Plan Administrator. AR 000107; AR 000166.

B. Mr. Harris's Accident and Subsequent Treatment

On August 14, 2014, Mr. Harris had an accidental injury. (Doc. 42, p. 3, ¶ 4.) In his Dismemberment Claim Form (signed December 23, 2014), Mr. Harris wrote that: "I was walking in my yard and when I put my foot down my left tibia broke in several pieces." AR 004544.² Mr. Harris "went to Huntsville Hospital's emergency room where X-ray films revealed a non-displaced³ fracture of his left tibia." AR 004322. According to Mr. Harris's attorney, Eric Artrip, the hospital's records stated: " ‘Labs do not reveal evidence of recurrent cancer.’ " Id. At the hospital, "[Mr. Harris] was placed in a cast and advised to follow up with his physician." Id.

• On August 19, 2014, Mr. Harris consulted with Dr. Robert A. Maples. AR 003636. Dr. Maples stated that he would "over wrap [Mr. Harris's] short leg splint into a sort leg cast[,]" and would "discuss the case with Dr. Ginger Holt at Vanderbilt University with regards to treatment options going forward." Id. In his progress notes, Dr. Maples wrote: "Mr. Harris is a 45 year-old gentleman who has a history of malignant fibrous histiocytoma⁴ in his left leg with radiation and soft tissue coverage who sustained a fall while running resulting in a left tibia fracture on 8/14/14." AR 003636 (emphasis added).

• On August 26, 2014, Mr. Harris met with Dr. Holt. AR 002610. Dr. Holt prepared a letter in which she stated: "I am seeing this very pleasant 45-year-old gentleman in consultation at your request for a pathologic⁵fracture of the left tibia secondary⁶ to radiation necrosis.⁷ Alex's history dates back to 2001 where he had a malignant fibrous histiocytoma resected⁸ on 10/08/2001.... He had radiation therapy for a total of 60 gray⁹ completed on 01/31/2002." AR 002610 (emphasis added). She noted that he had "wound healing issues," but, after undergoing ten surgeries, his wound finally healed. Id. She noted that Mr. Harris's x-rays "shows the shattered bone fracture, radiation necrosis...." AR 002610 (emphasis added). She summarized that, "Overall, [Mr. Harris] has radiation necrosis fracture nondisplaced in the setting of a terrible soft tissue envelope and leg." AR 002611 (emphasis added). "[D]ue to his history of wound-healing issues, Dr. Holt recommended that Mr. Harris avoid any sort of procedure which might result in potential for re-infection. Taking her advice, Mr. Harris opted to proceed with ... further casting." AR 004322. Dr. Holt wrote: "He will need a prolonged treatment in the cast twice as long if not longer than a regular fracture would be treated in a cast for a tibia fracture. This is due to the radiation necrosis sustained with 60 gray radiation, the bones stripping from multiple surgical procedures, and the time that has lapsed in between." AR 002611 (emphasis added).

• On November 4, 2014, Mr. Harris met with Dr. Krishna Reddy. AR 002613. Dr. Reddy wrote: "He now presents with a fracture of his midshaft tibia, which is relatively undisplaced. This is in the setting of radiation induced osteonecrosis." AR 002613 (

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