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

COLEEN KEANE, Personal Representativefor the Estate of Shawn L. Keane, deceased, Plaintiff,

v.THE LINCOLN NATIONAL LIFE INSURANCE COMPANY, Defendant.

Case No. 1:11-CV-656

UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF MICHIGAN SOUTHERN DIVISION

Dated: September 18, 2012

HON. GORDON J. QUIST

OPINION

Plaintiff, Coleen Keane, as Personal Representative of the Estate of Shawn L. Keane, has sued Defendant, The Lincoln National Life Insurance Company (Lincoln National), under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq., seeking to recover accidental death and dismemberment benefits under a group policy issued to Shawn L. Keane's employer.¹ Pursuant to the Case Management Order entered on October 7, 2011, Lincoln National has filed the Administrative Record and the parties have filed cross motions for judgment based upon the Administrative Record in accordance with Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609 (6th Cir. 1998). For the reasons set forth below, the Court will deny Plaintiff's motion, grant Lincoln National's motion, and affirm Lincoln National's denial of benefits.

I. BACKGROUND

The Accident

On September 12, 2009, Shawn L. Keane (Keane) and his wife, Coleen Keane, were riding a personal watercraft in West Grand Traverse Bay, Michigan. As they rounded a buoy at slow speed, Keane, who was driving, fell into the water. Keane initially tried to climb back onto the watercraft but became fatigued and collapsed into the water. Because it was not properly fitted, Keane's life jacket fell off. Coleen jumped into the water and tried to hold Keane's head above the water while calling for help. A nearby fishing boat responded. After about twenty minutes, rescuers were able to pull Keane aboard the boat, where CPR was administered without success. Keane was taken to the marina, where medical responders attempted to resuscitate Keane. Regrettably, the medical responders' efforts failed, and Keane was pronounced dead. (Agreed Administrative R. (A.R.) at LN 127, 432.)

The Policy

At the time of Keane's death, Keane's employer, Superior Inspection Services, Inc., maintained an ERISA welfare benefit plan that provided basic life insurance coverage to eligible employees. The welfare plan was insured by Lincoln National pursuant to a group life insurance policy (Policy). In addition, because Keane was a company officer, he was eligible for accidental death and dismemberment (AD&D) benefits. The Policy provides for AD&D benefits, in pertinent part, as follows:

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.

. . . .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 these;

. . . .

(7) voluntary use of drugs; except when prescribed by a Physician;

. . . .

(Id. at 52.)

Keane's Prior Medical Conditions

Keane's medical records disclose a number of medical conditions that had been identified and treated prior to the accident. His medical conditions included hypertension, obesity, hyperlipidemia (fatty deposits in the blood), diabetes,² bilateral lower leg neuropathy, knee pain, recent tarsal tunnel surgery, post cervical discectomy with fusion, right brachial plexopathy, and situational anxiety/depression. (Id. at 433.) Keane had been prescribed, among other drugs, Methadone for treatment of lower extremity pain due to neuropathy. (Id. at 402, 433.)

Post-Mortem Investigation

On September 13, 2009, Dr. Matthew A. Houghton Jr., the Grand Traverse County Medical Examiner, conducted a post-mortem physical examination of Keane. An autopsy was not performed.³ A post-mortem x-ray of Keane's chest showed that Keane's "lungs and pleural spaces" were clear; there was no pneumothorax (collapsed lung)⁴ indicating a chest injury; and there was "no evidence of an acute cardiopulmonary process." (Id. at LN 220.) A toxicology screen found a Methadone concentration in Keane's bloodstream of 2305 ng/mL - a concentration that exceeded the lethal range. (Id. at LN 141, 376.) In addition, a toxicology report and statements in the death-scene investigator's reports initially indicated that Keane had a blood alcohol level of .23% or .29%. (Id. at LN 223, 432.) Subsequently, however, the toxicology report was corrected to show that Keane was "negative" for alcohol. (Id. at LN 202, 217.)

Dr. Houghton determined the immediate cause of death to be "Acute Myocardial Infarction" (heart attack) due to "Near Larygospastic [sic] Dry Drowning"⁵ due to "Methadone Toxicity." Dr. Houghton listed hypertension and obesity as "Other Significant Conditions." (Id. at LN 433.) The Death Certificate, which Dr. Houghton signed on September 18, 2009, lists the cause of death, the conditions giving rise to the cause, and the approximate interval between onset and death for each as follows:

a. Acute Myocardial Infarction 4 min.

b. Near Laryngospastic Dry Drowning 8 min.

c. Methadone Toxicity 2 hrs.

(Id. at LN 448.) The Death Certificate also lists "Hypertension" and "Obesity" as "[o]ther significant conditions contributing to death but not resulting in the underlying cause given in Part I." (Id.) Dr. Houghton listed the manner of death as an "[a]ccident," as opposed to "suicide, homicide, natural, indeterminate or pending." (Id.)

On December 3, 2009, Dr. Richard Burke, M.D. - the physician who treated Keane for his lower extremity pain and prescribed Methadone to treat Keane's pain - wrote to Plaintiff's counsel, with a copy to Dr. Houghton, stating that Keane's death was not related to the level of Methadone in his blood. Dr. Burke explained:

This patient has been a long term patient of the Munson Medical Center Spine and Nerve Pain Treatment Center. Patient had intractable bilateral lower extremity pain due to neuropathy. He was treated with multiple analgesic medications including methadone. He developed a tolerance to methadone over time and his dosage hadbeen gradually increased to 150 mg per day. . . . Patient's dosage was stable. The day of his death the patient was very active, as is well documented, and was not clinically toxic with methadone even though chemically postmortem blood samples demonstrated that he had toxic methadone levels. Clinically he was not altered in any way from his methadone therapy. His death was deemed to be related to cardiopulmonary cause by Dr. Matt Houghton and was not related to the methadone levels which were present in his blood, presumably at these levels for many years.

(Id. at LN 153.) In response to Dr. Burke's letter, Dr. Houghton amended Keane's Death Certificate on February 3, 2010, to remove "Methadone Toxicity" as an underlying cause of death. (Id. at LN 152.) Thus, the Amended Death Certificate identified the chain of events leading to Keane's death as "Acute Myocardial Infarction" (4 mins.) and "Near Larygospastic [sic] Dry Drowning" (8 mins.), with "Hypertension" and "Obesity" as "other significant conditions contributing to death." (Id.)

Lincoln National's Claim Denials

Lincoln National paid Plaintiff's claim for basic life insurance benefits under the Policy in the amount of $150,000, and Plaintiff retained her present counsel to pursue her claim for AD&D benefits.

Initially, Lincoln National denied Plaintiff's claim in a decision issued on August 24, 2010, based on the exclusion for "[d]riving while intoxicated." (Id. at LN 229-30.) This decision was based on the incorrect toxicology report. (Id. at LN 229.) Lincoln National later retracted its reason for the denial based on corrected information showing that Keane's alcohol level was "negative." (Id. at LN 205.) Following Lincoln National's initial denial, Dr. Houghton wrote to Lincoln National explaining that "[w]ith [Keane's] history of Hypertensive Cardiovascular Disease, severe Obesity, Diabetes mellitus and Hyperlipidemia, it is within medical reason to include [sic] that he suffered a heart attack as an added result of his Near Larygospastic [sic] Dry Drowning while struggling in attempt to re-board the water-craft." (Id. at LN 188.) Citing Dr. Burke's prior letter, Dr. Houghton also said that the blood level of Methadone in Keane's system was "not unexpected due to his tolerance, developed-over time, to Methadone therapy." (Id.)

On October 26, 2010, Lincoln National issued a second denial, citing Keane's history of hypertensive cardiovascular disease, severe obesity, diabetes mellitus, and hyperlipidemia, and Dr. Houghton's statement that these conditions contributed to the heart attack that Keane suffered as a result of his near laryngospastic dry drowning. (Id. at LN 204-07.) While Lincoln National "agree[d] that Mr. Keane did experience an accident when he fell off the Jet Ski he was piloting," (id. at LN 205), it concluded that denial of AD&D benefits was appropriate because Keane's medical conditions contributed to his death. Thus, Lincoln National denied coverage because the accident was not the sole cause of death and the second limitation for "disease, bodily or mental infirmity, or medical or surgical treatment of these" precluded coverage. (Id. at LN 206.)

Plaintiff appealed the denial and, in support of her appeal, submitted sworn testimony from Dr. Houghton. As part of its review, Lincoln National retained Dr. Richard E. Sall, M.D., who is Board certified in Forensic Medicine, General Surgery, and Occupational Medicine, to review the record and prepare a report containing his forensic analysis of the cause of Keane's death. Dr. Sall concluded that the immediate cause of death was a cardiac arrhythmia, or an irregular heartbeat. (Id. at LN 141.) In...