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Harris v. Lincoln National Life Insurance Co.

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

February 7, 2019

ALEXANDER J. HARRIS, Plaintiff,
v.
LINCOLN NATIONAL LIFE INSURANCE CO., 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Judgment, (respectively Doc. 40, & 28), and Lincoln's former motion for summary judgment (Doc. 12) which has now been superseded.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         For the reasons stated below, Lincoln's Motion for Summary Judgment (Doc. 12) is due to be DENIED as superseded, Lincoln's Reformatted Motion for Summary Judgment (Doc. 40) is due to be GRANTED, and Mr.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 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 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 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-displaced[3] 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 histiocytoma[4] 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: '¶ am seeing this very pleasant 45-year-old gentleman in consultation at your request for a pathologic[5] fracture of the left tibia secondary[6] to radiation necrosis.[7] Alex's history dates back to 2001 where he had a malignant fibrous histiocytoma resected[8] on 10/08/2001. ... He had radiation therapy for a total of 60 gray[9] 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 (emphasis added). Dr. Reddy stated that "the fracture is not yet united . . . ." Id. Dr. Reddy wrote, "We feel this fracture is unlikely to go into healing secondary to radiation induced osteonecrosis from his previous treatments of sarcoma."[10] AR 002613 (emphasis added). Dr. Reddy discussed surgical treatment options with Mr. Harris including: posterolateral plating, an ipsilateral vascularized[11] fibular graft and plating, and amputation. Id. Mr. Harris opted for a bone graft and plating. Id.
• On November 21, 2014, Dr. Holt and Dr. Douglas Welkert performed a bone graft on Mr. Harris. AR 002615. In his Operative Report, Dr. Welkert stated: "ALEXANDER HARRIS is a 45 year old Male presenting with nonunion of the tibia secondary to radiation and previous sarcoma resection of leg." AR 002615 (emphasis added). He went on to write: 'The patient's past medical history is significant for a previous sarcoma resection of the left leg. The patient received radiation therapy as a part of his cancer treatment. The patient developed an osteonecrosis of his tibia with subsequent fracture and nonunion." Id. (emphasis added).
• In her Operative Report, Dr. Holt described the postoperative diagnosis as: "Pathologic fracture of the left midshaft tibia secondary to radiation osteonecrosis and periosteal stripping following soft tissue sarcoma resection and infection."[12] AR 002617 (emphasis added).

         C. Mr. Harris Returns to the Hospital and is Admitted at Vanderbilt

         Three days after the surgery, Mr. Harris was ambulatory at the hospital and using a rolling walker. AR 004323. He had fever and pneumonia-like symptoms, nevertheless, he was discharged on November 26, 2014, "with symptoms of fatigue, a low-grade fever and drainage from a prior flap site." Id. Mr. Harris had persistent fevers and general feeling of illness; thus, he went to a hospital emergency room. AR 002621; AR 004323. On December 8, 2014, he was then transferred from that hospital to Vanderbilt University Medical Center. AR 002625; AR 004323.

• On December 8, 2014, Dr. William Grantham examined Mr. Harris and drafted a report in which he described Mr. Harris's medical history, "He has history of malignant fibrous histiocytoma that was excised in 2001 and had subsequent radiation therapy from which he had a pathological fracture of his left tibia this year." AR 002621 (emphasis added). In his assessment of Mr. Harris, Dr. Grantham wrote, "Mr. Harris is a 45-year-old man status post a left vascular fibula graft for a tibial pathologic fracture who has a fever of unknown origin." AR 002622 (emphasis added). Dr. Grantham tentatively planned that Mr. Harris be "boarded for irrigation and debridement pending the results of the workup[, ]" and admitted Mr. Harris to the Orthopaedic Oncology service. Id.

         D. Mr. Harris Undergoes Amputation Procedure

         Upon admission to Vanderbilt, Mr. Harris also met with Dr. Holt. AR 002625. Dr. Holt discussed with him that if he had an infection Dr. Holt would proceed with an amputation. Id. Dr. Holt reported that a test revealed that his leg was infected with MRSA. Id. On December 10, 2014, Dr. Holt met with Mr. Harris to discuss with him the need to amputate his leg and Mr. Harris consented. That day, Dr. Holt performed a below knee amputation on Mr. Harris's leg. Id.

• In her December 10, 2014, Operative Report, Dr. Holt diagnosed Mr. Harris in both her pre and post operative diagnosis as: "Radiation necrosis, nonunion, osteomyelitis, left tibia." Id. (emphasis added).

         E. Mr. Harris's Claim and Lincoln's Denial of Benefits

         On December 23, 2014, Mr. Harris signed a Dismemberment Claim Form in which he claimed $57, 500 under the Basic Policy and $280, 000 under the Voluntary Policy. AR 004544. He wrote that on August 16, 2014: "I was walking in my yard and when I put my foot down my left tibia broke in several pieces. Attempts to repair it were unsuccessful and resulted in amputation of my left leg below the knee." AR 004544. Attached to the form was an Attending Physician's Statement completed by Dr. Holt. AR 004545. In response to the question, "Was the loss caused by an Accident?" Dr. Holt checked the box "No." Id. She confirmed that Mr. Harris underwent an amputation procedure. Id.

         On February 17, 2015, a Lincoln employee contacted Mr. Harris and requested additional medical records, because Dr. Holt indicted that his amputation was not due to an accident. AR 002578. That same day, Lincoln sent Mr. Harris a letter requesting additional information including: medical records, hospital records, CT scan results, MRI results, and office visit notes. AR 004530.

         On March 17, 2015, Lincoln sent Mr. Harris a letter again requesting the same additional information. AR 004528. The letter requested that the information be provided within 15 days, and stated that the claim file would otherwise be closed. Id. On March 30, 2015, Lincoln sent Mr. Harris a letter stating that his "file is being closed due to insufficient information." AR 004524. Lincoln wrote that if the documentation was later provided, then Lincoln would continue its review. AR 004524.

         On April 29, 2015, Mr. Artrip, on behalf of Mr. Harris, sent Lincoln a letter stating, "We are in the process of obtaining all relevant medical records and will provide them to you when received. Please provide a copy of the policy including any and all endorsements and exclusions." AR 004523. On August 18, 2015, Mr. Artrip sent Lincoln a letter including medical records. AR 004321. Mr. Artrip acknowledged that 15 years previously Mr. Harris had been diagnosed with malignant fibrous histiocytoma in his left leg. Id. Mr. Artrip stated that Mr. Harris "was functional and disease free" at the time of his injury. Id. In his letter, Mr. Artrip described the accident as Mr. Harris "running across an overgrown vacant lot" and that "[h]e stepped in a hole covered by long grass and broke his leg." AR 004322. On May 7, 2015, Lincoln sent Mr. Artrip copies of the Policies. AR 004521.

         Lincoln asked its employee, [13] Fil Castillo, RN, to review Mr. Harris's claim. AR 002580; AR 00189; (Doc. 12, p. 19). Mr. Castillo concluded: "The medical findings indicate that the loss was not caused by an acute accidental injury. The medical findings indicate that the loss was a result of complicated chronic medical conditions i.e. malignant fibrous histiocytoma resection, radiation osteonecrosis, infection, non union fx[.]" AR 000188. Mr. Castillo based his reasoning on the following facts:

• 'The medical records indicate that the claimant was chasing his dog and felt a snap in his leg and fell to the ground" AR 000189.
• "Xrays showed a nondisplaced pathological fracture in the setting of the surgical bed and surgical field." Id.
• 'The 8/26/14 medical records noted that the claimant's pathological fx of the left tibia was secondary to radiation necrosis." Id.
• 'The 11/21/14 op report noted that the pathological fx of the left tibia was secondary to radiation osteonecrosis and periosteal stripping following soft tissue sarcoma resection and infection." Id.
• 'The 2/9/15 [Attending Physician Statement] noted that the left [below knee amputation] loss was not caused by an accident." Id.

         On September 9, 2015, Lincoln sent Mr. Artrip a letter denying Mr. Harris's claim. AR 002712. Lincoln reasoned that the Mr. Harris's 'loss was a result of complicated chronic medical conditions from malignant fibrous histiocytoma resection, radiation osteonecrosis and infection." AR 002713. Lincoln also noted that the denied claim could be reviewed. Id.

         F. Mr. Harris Appeals and Lincoln Denies Benefits

         On November 6, 2015, Mr. Harris's attorney, Glen Connor, sent Lincoln a letter requesting "documents relevant to [Mr. Harris's] claim, including a copy of your entire claim file . . . ." AR 002709. That same day, Mr. Connor, sent Lincoln a separate letter (characterized as a "second level appeal") appealing Lincoln's initial determination. AR 002683. Mr. Connor sent Lincoln a declaration by Mr. Harris, AR 002686-87, and other medical documents. AR 002688-707.[14]

         In his November 6, 2015, declaration, Mr. Harris stated that his injury occurred on August 16, 2014, because while he was jogging his foot was suddenly stopped by something on the ground and it caused him to fall. AR 000266. He described the events in relevant part as follows:

In order to capture the dog, I needed to leave my yard and cross a vacant lot adjacent to my yard. . . . The terrain is hard, bumpy and irregular. Because of the weeds and grass and patchy ground, it was very difficult to see exactly where I was stepping.
As I was jogging across the vacant lot, my foot was suddenly stopped. The stop was sufficiently sudden and I was moving sufficiently fast that my momentum caused me to flip and I landed flat on my back. In other words, I tripped. ... I was immediately in a great deal of pain. I tried to walk and fell again. . . .
To be clear, the break did not happen just because I was walking or running. . . . What caused my injury was the fact that my foot was suddenly stopped and caused a fall. My impression at the time was that I had stepped into a hole. All I know for certain is that my foot stopped and I went down. Whether the break was caused by the sudden stop or the fall I cannot tell, but I do know that the break did not just happen when I took a step, it happened when I tripped, whether in a hole or other obstacle.
I have consistently told my physicians that this is what happened. None of my physicians have ever closely examined or questioned me as to the precise facts of the injury and they never showed me their notes, so I do not know their understanding of how the accident occurred. . . .
Prior to August 16, 2014 I had not had any problems with my leg since the surgery and treatment in 2001 and 2002. It functioned normally, though I had limited range of motion in the ankle. ... In short, I was able to use ...

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