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CASEY v. UDDEHOLM CORP.

July 20, 1993

DANIEL T. CASEY, Plaintiff,
v.
UDDEHOLM CORPORATION, a New York corporation, UDDEHOLM HEALTH BENEFITS PLAN, and PACIFIC MUTUAL LIFE INSURANCE COMPANY, Defendants.


Kocoras


The opinion of the court was delivered by: CHARLES P. KOCORAS

CHARLES P. KOCORAS, District Judge:

 This matter comes before the Court on the motion for summary judgment of the defendants, Uddeholm Corporation and Uddeholm Health Benefits Plan. For the following reasons, the motion is granted.

 Daniel Casey filed this lawsuit seeking a review of a denial of health benefits. Casey incurred permanent and severe injuries as a result of being struck by a Chicago Transit Authority elevated train ("the CTA train") when he dove in front of it in an attempt to commit suicide. Casey subsequently presented a claim for over $ 300,000 in hospital bills and doctor's bills to the Administrator of the defendant Plan. The Administrator denied Casey's claim, interpreting the Plan to not provide coverage for injuries sustained as a result of a suicide attempt. After reviewing the Administrator's interpretation, we conclude that in specific circumstances, injuries sustained as a result of a suicide attempt are covered under the Plan.

 I. The Interpretation of "Injuries Sustained Accidentally"

 Because the Plan does not grant discretion to the Administrator to interpret its terms, we employ a de novo standard of review. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 103 L. Ed. 2d 80, 109 S. Ct. 948 (1989); Ziaee v. Vest, 916 F.2d 1204, 1208 (7th Cir. 1990), cert. denied, 113 L. Ed. 2d 646, 111 S. Ct. 1581 (1991); Petrilli v. Drechsel, 910 F.2d 1441, 1445-47 (7th Cir. 1990). After conducting our de novo review, we conclude that we cannot uphold the Administrator's interpretation of the Plan, and instead, we adopt an interpretation that would extend coverage for injuries sustained as a result of a suicide attempted while insane.

 The relevant terms of the Plan are briefly stated. The Plan provides basic medical benefits for participants who are "confined in a hospital as a result of a nonoccupational illness or injury. . . ." In addition, the Plan's major medical benefits cover medically necessary charges "due to Sickness or Injury . . . ." The definitions section of the Plan defines "injury" as an "Injury to the body that is sustained accidentally." The Plan, however, does not define "accidentally," and although the Plan contains nineteen exclusions, none of them deny coverage for injuries arising from attempted suicide or for injuries intentionally inflicted by the beneficiary.

 The Plan Administrator found that the Plan did not cover Casey's claim because his injuries were not sustained accidentally. The Administrator explained his decision in the following manner:

 
As I interpret the Plan, injuries that are sustained accidentally are those that are unexpected, unpremeditated, and unforeseen. See J. Appleman, Insurance Law & Practice, § 360, pp. 447-53 (1981). Thus, the issue is not whether Mr. Casey intended to injure himself. The issue is whether his injuries were the reasonably foreseeable consequence of what he did.
 
Here . . . the injuries suffered by Mr. Casey were the reasonably foreseeable or expected consequence of his jumping in front of a speeding CTA elevated train. Under these circumstances, his injuries cannot be considered to have been "sustained accidentally" within the meaning of the Plan.

 In addition, the Administrator addressed the argument that an act committed without intent is accidental. The Administrator held that "the express language of the Plan limits coverage for medical benefits to those injuries that are 'sustained accidentally.' Nowhere does it define accidental injuries as those that are not intended."

 The defendants argue that the Administrator's interpretation is consistent with the plain language of the Plan's medical benefits provisions. According to the defendants, the Plan's provisions do not require a finding that an injury was intentionally self-inflicted in order to be excluded from coverage; rather, the injury simply must be found not accidental. The defendants further suggest that the Administrator's interpretation is consistent with the fundamental principle of ERISA that the terms of a plan should be interpreted from the viewpoint of a plan participant of average intelligence and experience. Senkier v. Hartford Life & Acci. Ins. Co., 948 F.2d 1050, 1052-53 (7th Cir. 1991).

 We do not agree with the defendants that the plain language of the Plan dictates the Administrator's interpretation. The Plan does not define what it means by "accidentally." Nowhere does it state that "accidentally" is not to be equated with "unintended." In addition, the Plan nowhere specifically excludes coverage for injuries sustained as a result of suicide. Thus, the term "accidentally" could be read to incorporate an element of lack of intent without violating the plain language of the Plan.

 Beyond this, we find the Administrator's interpretation to be unclear. To the extent the Administrator interpreted the Plan to mean that any objectively foreseeable result of any act, even an act that is unintended, does not qualify as being accidentally caused, we think this interpretation is in error. In the alternative, the Administrator may have meant that Casey's attempted suicide was nonaccidental in the sense that Casey, and no other force, propelled himself into the train. Along these lines, the Administrator may have been suggesting that it does not matter whether Casey could not resist due to insanity because on one level, Casey acted purposefully, and purposeful action cannot be deemed an ...


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