Court Awards Accidental Death Benefits for Fatal Overdose of Prescription Medications
Long-term disability cases generate an enormous amount of litigation, almost always in federal court because of the scope of ERISA pre-emption. ERISA also bars state law claims, such as negligence and breach of contract, and compensatory and punitive damages. Thus, a claimant is typically limited to the amount of the benefits at issue in his or her claim and possibly an award of attorney’s fees.
Further, if the plan grants discretion to the administrator to make eligibility decisions, as many, if not most, plans do, the court is obligated to defer to the administrator’s decision, which means that unless the court finds that the administrator abused its discretion (the “arbitrary and capricious” standard), the court must affirm the decision, even if the court would have decided the issue differently.
But out of federal court for the Northern District of West Virginia comes a decision, admittedly with an atypical set of facts, which demonstrates that a plaintiff can prevail in an LTD claim. In Gower v. AIG Claim Services, Inc., 2007 WL 2119262 (N.D.W.Va.), Kathy Gower filed a claim for accidental death benefits resulting from the death of her husband, a 41 year old coal miner. AIG provided a group accident insurance policy through Peabody Holding Company, the parent of Gower’s husband’s employer, Eastern Associated Coal Corporation.
AIG investigated the death and found that at the time of his death, Gower’s husband was wearing four Duragesic patches that release fentanyl (which is prescribed for chronic pain management). An autopsy revealed the presence of other medications, including carisoprodol (a muscle relaxant), olanazapine (an anti-psychotic), and diazepam (a sedative), from which the medical examiner concluded that the death was the result of the combination.
AIG also hired a forensic toxicologist, who opined that Gower’s husband had deliberately applied the additional patches of fentanyl and thereby exceeded the prescribed dosage, and that his death was due to the combination of the fentanyl and olanazapine. Accordingly, AIG denied the claim because Gower’s husband’s death was caused “in whole or in part … from an intentionally self-inflicted injury or an attempt at intentionally self-inflicted injury.”
Gower appealed the denial and presented evidence from a pharmacist who explained that Gower’s husband had mistakenly taken the wrong drug, as well as her own affidavit regarding her husband’s condition and his apparent confusion about the various medications. AIG’s toxicologist submitted a follow-up report, and thereafter AIG affirmed its denial of the claim.
Chief Judge Irene M. Keeley first determined that the plan language “does not clearly establish the intent to grant final discretionary authority” to AIG, and applied a de novo standard of review to its denial of benefits. She then analyzed the two policy provisions upon which AIG relied: first, that Gower’s death did not result from an injury caused by an “accident”; and second, even if Gower’s death was an accident, AIG claimed that it was caused by an “intentionally self-inflicted injury.”
Because Judge Keeley's analysis runs for several pages (and I prefer this post not be that long), I'll summarize her conclusions. As to the first provision, she concluded that, “The totality of the evidence in the record weighs in favor of the conclusion that Gower did not expect his actions to result in death. He had insufficient knowledge and experience of drug interactions to realize the devastating results of the combined dosages, and he took only a small portion of the medications available to him. Gower, therefore, had a subjective expectation of survival that was reasonable, and the Court concludes that his death constitutes an accident within the meaning of the Policy’s provisions.”
Regarding AIG’s second assertion, that Gower’s death was caused by an intentionally self-inflicted injury, Judge Keeley held that, “What the totality of the evidence in the record does suggest is that Gower voluntarily took medications intending to temporarily relieve his pain and overall poor health, not to inflict any type of injury, much less to cause his own death. That an overdose occurred and resulted in death does not, of itself, provide the critical and necessary link to the requisite mental state. Accordingly, this Court holds that AIG’s Policy exclusion for loss caused in whole or in part by an intentionally self-inflicted injury does not apply in this case.”
Thereafter, Gower moved for an award of attorney’s fees, costs, and pre- and post-judgment interest. In Gower v. AIG Claim Services, Inc., 2007 WL 2327116 (N.D.W.Va.), the Court held that a review of the five factor test established by the Fourth Circuit did not entitle the plaintiff to attorney’s fees. Specifically, the Court found that AIG did not engage in bad faith by denying the claim, but demonstrated “mere negligence by misinterpreting the terms of the applicable insurance policy.”
The Court awarded costs in the amount of $195.60, and pre-judgment interest on the $70,000 benefit amount at 9.75% per annum and accruing on April 28, 2006 (when AIG affirmed the denial of the claim), and post-judgment interest on the total award at 5% per annum and accruing on July 20, 2007 (when the Court’s order granting summary judgment for the plaintiff).
Finally, the Court granted AIG’s motions to extend the time for filing a notice of appeal until the Court had ruled on the motion for attorney’s fees, which means that any notice has to be filed within 30 days of August 10. In its motion, AIG indicated that it had not decided whether to appeal the rulings.
