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March 24, 1992

JOAN HALEY, as Independent Administrator of the Estate of John Haley, deceased, Plaintiff,


The opinion of the court was delivered by: GEORGE M. MAROVICH


On October 23 1991, the plaintiff, Joan Haley ("Mrs. Haley"), acting in her capacity as administrator of the estate of her husband, John Haley ("Mr. Haley"), filed this action against American International Life Assurance Company of New York ("AI Life") to recover accidental death benefits Mrs. Haley claims are due under her husband's employee benefits plan ("plan"). The plan was issued by AI Life pursuant to the Employee Retirement Security Act (ERISA), 29 U.S.C. ยง 1132(a)(1)(B). Mrs. Haley filed this motion for summary judgment pursuant to Fed. R. Civ. P. ("Rule") 56. In her motion, Mrs. Haley contends that, as a matter of law, her husband's death constitutes "bodily injury caused by accident . . ." within the meaning of the plan and, therefore, that AI Life should not have denied her claim for accidental benefits. AI Life has filed a cross-motion for summary judgment. For the following reasons, we grant AI Life's cross-motion for summary judgment and deny Mrs. Haley's motion.


 On the morning of December 12, 1989, John Haley, fifty-three, left his home for work at approximately 8:00 a.m. When he left, he looked normal and appeared to be feeling fine. Mr. Haley returned home, however, about a half hour later complaining that he did not feel well. He told his wife that he was going to get a glass of water, undress and rest. A few minutes later, Mrs. Haley heard a glass break, ran into the bedroom and found her husband unconscious on the bed. Mrs. Haley called the paramedics and Mr. Haley was rushed to the emergency room at Edgewater Medical Center.

 When Mr. Haley arrived at Edgewater Medical Center, he was in a state of cardiopulmonary arrest. Despite the lengthy efforts of the attending physician, Dr. Thomas, to resuscitate Mr. Haley, he never regained consciousness. Although Mr. Haley had a history of heavy smoking and alcohol abuse, he had never experienced any difficulties with his heart or exhibited any indication or symptoms of heart disease.

 Dr. Thomas diagnosed Haley's condition at the time of death as "cardiopulmonary arrest." As the doctor explained, the diagnosis simply means that "he stopped breathing, his heart stopped working." Dr. Thomas concluded that Mr. Haley had suffered a heart attack which caused the cardiac arrest and that the heart attack had not been caused by any "trauma" or "foul play."

 Mr. Haley's death certificate indicates that the immediate cause of death was "atherosclerotic cardiovascular disease," which is the build-up of cholesterol plaques in the cardiovascular system. Although the presence of this disease cannot be determined without an autopsy, the medical examiner/coroner testified that he listed this disease as the cause of death for Mr. Haley because it is a common reason for death in similar circumstances. The medical examiner/coroner also concluded that Mr. Haley died of natural causes, the same conclusion that Dr. Thomas reached.

 At the time of his death, Mr. Haley was covered under an accidental death an dismemberment policy ("policy") issued to his employer, Rusch, Inc., by AI Life. *fn1" Rusch sponsored and maintained the policy with AI Life as part of Rusch's employee benefits plan. As a Rusch employee, and pursuant to a specific endorsement to the policy, Mr. Haley was a participant and Class II insured under the plan. It is undisputed that the policy was in full force and effect on the day Mr. Haley died.

 Under the policy, accidental death benefits of $ 100,000 are payable to Class II insured, including Mr. Haley, provided that conditions of the contract are met. The policy provides that it will pay its "Principle Sum" ($ 100,000") as an indemnity upon the death of an insured person if that death results from an "injury" as defined in the policy. The policy provides in part:

"Injury" wherever used in the policy means bodily injury caused by an accident and resulting directly and independently of all other causes in loss covered by the policy. . . .

 Following Mr. Haley's death, Mrs. Haley filed a claim with AI Life to recover accidental benefits under Class II of the policy. On June 25, 1990, AI Life formally denied Mrs. Haley's claim and notified her of her right to appeal this denial. In its denial letter, AI Life stated that after a review of both the medical records from Edgewater Medical Center and an interview with Mrs. Haley, it had determined that Mr. Haley's death did not fall within the policy's coverage for accidental death because "the death was not the result of an injury caused by an accident." The letter also stated that "this loss, which was a fatal heart attack, was due to natural causes and doesn't fall under the policy guidelines as a compensable loss." After AI Life denied her claim, Mrs. Haley filed the present action to recover the accident benefits under the policy. Both parties filed motions for summary judgment.


 Summary judgment is appropriate if "the pleadings, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue of material fact and that the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56. In a summary judgment proceeding, the court "must view the record and all inferences to be drawn from it in the light most favorable to the non-movant." Griffin v. Thomas, 929 F.2d 1210, 1212 (7th Cir. 1991). The movant's burden, however, "May be discharged by 'showing' . . . that there is an absence of evidence to support the non-moving party's case." Celotex Corp. v. Catrett, 477 U.S. 317, 91 L. Ed. 2d 265, 106 S. Ct. 2548 (1986).

 Benefit provisions of an ERISA group life insurance plan must be interpreted under principles of federal substantive law. Wickman v. Northwestern National Ins. Co., 908 F.2d 1077, 1084 (1st Cir.) cert. denied, 112 L. Ed. 2d 586, U.S. , 111 S. Ct. 581 (1990). Since federal common law on the issue of insurance benefits is still in its formative stage, a federal court should consider and draw upon all state court experiences that deal with factually similar situations in reaching its interpretation of an insurance plan. Id. at 1084; see also Senkier v. Hartford Life & Accident Ins. Co., 94 ...

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