Insurance Coverage – Causation

Listen to this article

7^th Circuit Court of Appeals

Case Name: Lee Ann Prather v. Sun Life and Health Insurance Company

Case No.: 16-1861

Officials: WOOD, Chief Judge, and POSNER and WILLIAMS, Circuit Judges

Focus: Insurance Coverage – Causation

The plaintiff’s decedent, Jeremy Prather, was employed by a company that had obtained a Group Insurance Policy from Sun Life which provided accidental death and dismemberment coverage for the company’s employees, in the amount of $92,000 for Prather. The policy limited coverage to “bodily injuries … that result directly from an accident and independently of all other causes.”

The clause we’ve italicized is the focus of this appeal from the district court, which granted summary judgment for Sun Life, which had invoked the clause to deny the payment of death and dismemberment coverage to Prather’s survivor on the ground that his death had not been the exclusive result of an accident—it had also been the result of “complications from surgical treatment.” Prather’s widow brought this suit “to recover benefits due to [her]” under the plan. 29 U.S.C. § 1132(a)(1). On July 16, 2013, Prather, age 31, had torn his left Achilles tendon playing basketball. Three days later he met with an orthopedic surgeon to discuss treatment, and of the options offered he chose surgery. He was scheduled to be operated on three days later, July 22. On July 21 he called the surgeon’s office complaining of a swelling in the lower part of his left leg, and that an area of the left calf was both sensitive and warm to the touch. The surgeon told him to elevate the leg. The surgery next day to repair his torn Achilles tendon was uneventful and he was discharged from the hospital the same day. He returned to work and was reported as doing well in a follow-up visit to his surgeon on August 2. But four days later he collapsed at work, went into cardiopulmonary arrest, and died the same day as a result of a deep vein thrombosis (blood clot) in the injured leg that had broken loose and traveled through the bloodstream to a lung, thus becoming a blood clot in the lung—that is, a pulmonary embolism—which caused cardiac arrest and sudden death.

Reversed

Full Text

Attorney Derek A. Hawkins is the managing partner at Hawkins Law Offices LLC, where he heads up the firm’s startup law practice. He specializes in business formation, corporate governance, intellectual property protection, private equity and venture capital funding and mergers & acquisitions. Check out the website at www.hawkins-lawoffices.com or contact them at 262-737-8825.