United States District Court, N.D. Illinois, Eastern Division
LAURA YASKO, on behalf of ALAN YASKO. M.D., Plaintiff,
STANDARD INSURANCE COMPANY, Defendant.
MEMORANDUM OPINION AND ORDER
SIDNEY I. SCHENKIER, Magistrate Judge.
This case is before the Court on the cross-motions for summary judgment brought by Laura Yasko, on behalf of Alan Yasko, M.D. (doc. #27), and defendant Standard Insurance Company ("Standard") (doc. #30). Ms. Yasko brought this action pursuant to the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a), as the surviving spouse and named beneficiary of Dr. Alan Yasko, challenging the denial of accidental death benefits (doc. #1: Complaint). Prior to his death, Dr. Yasko was a professor of orthopedic surgery at Northwestern University's Feinberg School of Medicine and served as Chief of Musculoskeletal Oncology at Northwestern's Robert H. Lurie Comprehensive Cancer Center (doc. #29: Plaintiff's Local Rule 56.1 Statement of Material Facts ("Pl.'s SOMF") at ¶ 11). As part of his compensation, Dr. Yasko participated in an employee welfare benefit plan maintained by Northwestern Medical Faculty Foundation ("Northwestern") for its eligible employees, which included life insurance and accidental death and dismemberment ("AD&D") insurance coverage underwritten and administered by defendant Standard (Pl.'s SOMF at ¶¶ 1, 6; doc. #32: Standard Insurance Company's Local Rule 56.1 Statement of Material Facts ("Def.'s SOMF") at ¶ 1). Ms. Yasko challenges the denial of benefits totaling $1, 200, 000.00 under Standard's insurance policy following her husband's death in Mexico, where he had traveled by air to speak at a medical conference (Pl.'s SOMF at ¶¶ 1, 6, 17; doc. #28: Memorandum in Support of Plaintiff's Motion for Summary Judgment ("Pl.'s Mem.") at 1-2). Ms. Yasko contends that Dr. Yasko's death was caused by a pulmonary embolism "triggered by extensive air travel, " and that consequently, it was accidental (Pl.'s SOMF at ¶ 22). Standard argues, however, that it properly denied coverage because Dr. Yasko's death was not caused by a bodily injury sustained in an accident, as required by the policy's accidental death clause (doc. #36: Standard Insurance Company's Memorandum in Support of its Motion for Summary Judgment ("Def.'s Mem.") at 11-15).
For the reasons set forth below, the we grant the defendant's motion for summary judgment, and deny the plaintiff's motion for summary judgment.
The following facts are drawn from the pleadings and the parties' Local Rule 56.1 submissions. The facts are undisputed unless otherwise noted by the Court. As part of its employee benefits plan, Northwestern provided Dr. Yasko with life insurance and AD&D insurance coverage under Group Life Insurance Policy, Group Policy No. 136810-A, issued by Standard (Pl.'s SOMF at ¶ 1; Def.'s SOMF at ¶ 1). The policy provides, in relevant part:
The AD&D Benefit
... will be paid by Standard, if you are insured for accidental death & dismemberment insurance under the Group Policy and:
(1) you sustain bodily injuries as a result of an accident; and
(2) as a result, you suffer one of the following losses within 365 days after the date of the accident:
(a) Loss of life. Standard will pay 100% of the full amount. Proof of Loss satisfactory to Standard must be received before the accidental death and dismemberment insurance under the Group Policy will be paid.
No AD&D Benefit Will Be Paid
... if your death or other loss is caused by:
(1) a disease or illness of any kind, or medical or surgical treatment of these, except those resulting from purely accidental circumstances.
(Pl.'s SOMF at ¶¶ 9, 10; Def.'s SOMF at ¶ 5). The "Benefits at a Glance" section of the policy states: "No AD&D Will Be Paid... if your death or other loss is caused by: (1) A disease or illness of any kind, including heart attack or stroke..." (Def.'s SOMF at ¶ 6; doc. #46: Plaintiff's Response to Defendant's Local Rule 56.1 Statement of Material Facts ("Pl.'s Resp.") at ¶ 6). Finally, the policy specifies that Standard has "Discretionary Authority For Claims, " and states: "Benefits will be provided only if Standard decides in its discretion that you are entitled to them. This discretionary authority includes determining eligibility for benefits and interpreting the terms of the Group Policy" (Pl.'s SOMF at ¶ 11; Def.'s SOMF at ¶ 9).
In March 2010, Dr. Yasko was diagnosed with a carcinoid tumor in the left lower lobe of his lung (Pl.'s SOMF at ¶ 12; Def.'s SOMF at ¶ 11). On March 23, 2010, Dr. Yasko was admitted to MD Anderson Cancer Center at the University of Texas in Houston, and underwent surgery, performed by Dr. Ara Vaporciyan, to remove the carcinoid tumor, a portion of the lower lobe of his left lung, and thirteen lymph nodes, as well as to repair a damaged section of the pulmonary artery (Pl.'s SOMF at ¶¶ 13, 14; Def.'s SOMF at ¶¶ 12-13). One of the thirteen lymph nodes tested positive for metastasis (Pl.'s SOMF at ¶ 14 n.3; Def.'s SOMF at ¶ 13). At a follow-up visit on April 23, 2010, Dr. Yasko stated that he had experienced occasional chest tightness, intermittent gurgling while reclining, numbness in the left anterior chest, and mild fatigue (Def.'s SOMF ¶ 16; Pl.'s Resp. at ¶ 16). Dr. Yasko reported that he had returned to work, "has had 2 clinics and assisted in an 8-hour surgery, " and had "no difficulty other than mild fatigue" (Def.'s SOMF ¶ 16; Pl.'s Resp. at ¶ 16). He was instructed to return in six months for a CT scan of his chest and again at the one-year anniversary of his surgery to undergo a fiberoptic bronchoscopy (Def.'s SOMF ¶ 16; Pl.'s Resp. at ¶ 16).
On August 16, 2010, Dr. Yasko traveled by air from Chicago to Houston, and on August 18, 2010, Dr. Yasko flew from Houston to Mexico to speak at a medical conference (Pl.'s SOMF at ¶ 17; Def.'s SOMF at ¶ 40). He arrived in Quintana Roo, Mexico around 4:00 pm and was greeted by a colleague, Dr. Carlos Cuervo Lozano,  who noted that Dr. Yasko appeared to be tired and perspiring (Pl.'s SOMF at ¶ 17; Def.'s SOMF at ¶ 29). Dr. Lozano asked Dr. Yasko if he felt well, and Dr. Yasko replied affirmatively (Def.'s SOMF at ¶ 29; Pl.'s Resp. at ¶ 29). Although there was a reception for conference attendees that night, Dr. Yasko did not attend, and at 5:00 a.m. the next morning, Dr. Lozano was summoned to Dr. Yasko's hotel room, where Dr. Lozano found him in respiratory failure (Pl.'s SOMF at ¶ 18; Def.'s SOMF at ¶¶ 29-30; Pl.'s Resp. at ¶¶ 29-30). Dr. Yasko was given artificial respiration until the ambulance arrived, but slipped into unconsciousness before he could be transported to a local hospital (Pl.'s SOMF at ¶ 18; Def.'s SOMF at ¶ 30; Pl.'s Resp. at ¶ 30). Dr. Lozano did not accompany Dr. Yasko to the hospital because he had to attend to conference activities (Def.'s SOMF at ¶ 30; Pl.'s Resp. at ¶ 30).
An ambulance took Dr. Yasko to Hospiten Hospital in Playa Del Carmen, Quintana Roo, where he died around 7:00 a.m. that morning (Pl.'s SOMF at ¶ 19; Def.'s SOMF at ¶¶ 19, 31, 32; doc. #47: Standard Insurance Company's Response to Plaintiff's Local Rule 56.1 Statement of Material Facts ("Def.'s 56.1 Resp.") at ¶ 19). At the hospital, Dr. Oscar Hernandez Gea, the doctor who had attempted to save Dr. Yasko's life, certified the causes of death as massive pulmonary thromboembolism and lung cancer (Pl.'s SOMF at ¶ 19; Def.'s SOMF at ¶ 20; Def.'s 56.1 Resp. at ¶ 19; Pl.'s Resp. at ¶ 20). In addition, Dr. Yasko's death certificate states that his death was due to natural causes (Def.'s SOMF at ¶ 20; Pl.'s Resp. at ¶ 20). Dr. Lozano reported that he had not known that Dr. Yasko suffered from lung cancer and had undergone surgery, but only found this out when the doctors who attended to Dr. Yasko at the hospital so informed him, and because he saw an x-ray, which he said "showed [that] a pulmonary embolism was apparently the cause of [Dr. Yasko's] death" (Def.'s SOMF at ¶ 30; Pl.'s Resp. at ¶ 30). No x-rays were submitted to Standard, and no charges for x-rays appear on the hospital services invoice (Def.'s SOMF at ¶ 33; Pl.'s Resp. at ¶ 33). No autopsy was performed, and Dr. Yasko's body was cremated (Def.'s SOMF at ¶ 23; Pl.'s Resp. at ¶ 23).
On November 9, 2010, Plaintiff submitted a claim to Standard for basic and additional life insurance benefits, and basic and additional AD&D benefits (Pl.'s SOMF at ¶ 20; Def.'s SOMF at ¶ 25; Pl.'s Resp. at ¶ 25). Standard obtained Dr. Yasko's medical records from Northwestern University Hospital, MD Anderson Cancer Center, and the Hospital Riviera Maya and retained Diligence International Group to travel to Mexico to investigate his death (Def.'s SOMF at ¶¶ 26-27; Pl.'s Resp. at ¶¶ 26-27). The investigators obtained official death certificates, reviewed medical records, and interviewed hotel and hospital personnel, a United States Consulate official, and the owner of the funeral home that performed the embalming (Def.'s SOMF at ¶ 27; Pl.'s Resp. at ¶ 27).
On February 14, 2011, Standard wrote Ms. Yasko a letter approving her claim for basic and additional life insurance benefits in the total amount of $1, 200, 000.00, plus interest (Def.'s SOMF at ¶ 34; Pl.'s Resp. at ¶ 34). In that same letter, Standard notified Ms. Yasko that it was declining her claim for basic and additional AD&D benefits because it concluded that Dr. Yasko's death was not the result of bodily injuries sustained as a result of an accident (Pl.'s SOMF at ¶ 21; Def.'s SOMF at ¶ 35). On October 24, 2011, Ms. Yasko, through her attorney, appealed Standard's decision declining AD&D benefits, asserting that Dr. Yasko's "extended demobilization" during air travel "caused a blood clot in his leg to be released and cause a pulmonary embolism" (Pl.'s SOMF at ¶ 22; Def.'s SOMF at ¶¶ 36-37; Pl.'s Resp. at ¶¶ 36-37; doc. #31: Appendix to Standard Insurance Company's Motion for Summary Judgment Administrative Record, Volumes I-IX at STND XX-XXXX-XXXXX). Her attorney also contended that prolonged sitting in an airplane was "analogous" to being in a "car accident, which then caused a blood clot to dislodge and cause a heart attack" (Def.'s SOMF at ¶ 37; Pl.'s Resp. at ¶ 37; STND XX-XXXX-XXXXX). ...