EASTERN DISTRICT OF TEXAS FINDS INSURER ACTED REASONABLY IN ITS DECISION TO DENY DEATH BENEFITS BASED ON ITS DETERMINATION THAT THE DECEDENT DIED FROM A PRE-EXISTING HEART CONDITION

In Daly v. Standard Ins. Co., 2:11-CV-001-JRG-RSP, 2014 WL 111688a6 (E.D. Tex. Mar. 18, 2014), the Marshall Division of the U.S. District Court for the Eastern of District of Texas adopted a magistrate’s recommendation to deny plaintiff’s life insurance benefits on a group life insurance policy issued by Standard Insurance Company on the life of plaintiff’s late husband. The claim was covered by ERISA since the policy was part of the employee benefit plan of Southwest Airlines for whom plaintiff’s late husband was a pilot at the time of his death.

The sole issue the Court decided was whether accidental death benefits are unavailable because a policy excludes such benefits where the death is “caused or contributed to by…sickness…existing at the time of the accident [or] hearth attack or stroke.” The insurer argued that plaintiff’s husband had heart/chest problems before he had a syncopal episode (fainting) which resulted in a fatal injury to his head.  On the other hand, the carrier contended the medical records showed her husband’s heart problem was the result of the fall, rather than the cause of it.

The Court considered a substantial amount of medical evidence to determine the cause of her late husband’s fall.  Before her husband passed away, plaintiff called Mother Frances Hospital and reported that her husband showed signs of an upper respiratory type infection, was having mild chest pain, and was becoming diaphoretic, cold, and clammy.  She also told the triage staff he was 61 years old and had no chronic medical issues.  She spoke with several doctors about her husband’s symptoms, including a cardiologist who noted that Ms. Daly described her husband as “coming down with a cold” and noting he experienced chest pressure and pain which radiated to his right arm. Another consultation report noted plaintiff’s husband was suffering from pneumonia.

After her phone calls with the consulting doctors, plaintiff decided to take him to the emergency room.  She drove up to the emergency room entrance where her husband got out of the car and walked into the emergency room while she found a parking spot.  While her husband was waiting at the receptionist’s desk, he fainted and fell to the floor, severely hitting his head.

The Court found the triage notes from plaintiff’s consultation with several doctors before bringing her husband to the emergency room most persuasive.  The Court noted that the deceased complaints to his wife about chest pressure were due to his cold or pneumonia.  Further, the fact that the attending physician, who had no relationship with the insurer, concluded that her husband’s fainting episode was “probably secondary to a cardiac event,” makes it impossible for the Court to conclude the insurer was unreasonable in finding that a pre-existing heart condition “caused or contributed to” Plaintiff’s husband’s death.  As such, the Court dismissed Plaintiff’s claims with prejudice.