Thomas v. AIG Life Insurance

REVISED - March 28, 2001

UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT

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No. 99-41504
Civil Docket #5:98-CV-21
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TIBBY THOMAS,

Plaintiff-Appellant,

versus

AIG LIFE INSURANCE COMPANY,

Defendant-Appellee.
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Appeal from the United States District Court
for the Eastern District of Texas
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March 7, 2001

Before JOLLY, JONES, and SMITH, Circuit Judges.

EDITH H. JONES, Circuit Judge:

The question in this case is whether a death resulting

from complications following stomach stapling surgery was “caused

by an accident” under an ERISA-governed insurance policy. We

affirm the district court’s conclusion that this death was not

accidental.

Appellant Tibby Thomas’s husband owned, through his

employer, two accidental death insurance policies with AIG Life
Insurance Company (“AIG”). Under the policies, Mrs. Thomas was

entitled to benefits if Mr. Thomas suffered a “loss resulting from

injury.” The policies defined injury as “bodily injury caused by

an accident . . . resulting directly and independently of all other

causes . . .” Excluded from the policies were “diseases of any

kind” and “bacterial infections except pyogenic infections which

shall occur through an accidental cut or wound.”

Mr. Thomas suffered from morbid obesity. He had two

stomach stapling surgeries to treat this disease. Following the

second surgery, Mr. Thomas’s sutures broke and he died from sepsis.

Mrs. Thomas filed for benefits under the policies. AIG’s ERISA

Appeals Committee ultimately rejected her claim, and Mrs. Thomas

filed suit. The district court held that because Mr. Thomas’s

death was not accidental under the policies, Mrs. Thomas was not

entitled to benefits. Mrs. Thomas appeals.

The parties dispute the standard of review for AIG’s

decision that Mr. Thomas’s death was not accidental. They concur

that AIG had no discretion as a plan administrator to interpret the

policies. They part company over whether the determination of

accidental death is factual, and reviewed under an abuse of

discretion, or legal, and governed by a de novo standard. See,

generally, Pierre v. Connecticut Life Ins. Co., 932 F.2d 1552, (5th

Cir. 1991). Because Pierre specifically applied the abuse of

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discretion standard to an accidental death finding, we do so as

well.

Mrs. Thomas asserts that she is entitled to benefits

because Mr. Thomas’s death was caused by an accident that took

place during his operation. The Seventh Circuit rejected this type

of argument in a similar case. Senkier v. Hartford Life & Accident

Ins. Co., 948 F.2d 1050 (7th Cir.1991). In Senkier, a patient

receiving treatment for an intestinal disease died when a migrating

intravenous catheter punctured her heart. Her estate argued that

the death was an accident under her insurance policy. The court

held that the patient’s death resulted from her underlying illness.

It refused to characterize the death as an accident under the

policy because it occurred “from the standard complications of

standard medical treatment” for a disease. Id. at 1053.

The Fourth Circuit has stated that a patient’s death was

“accidental” under an accidental death policy where he received an

infected I.V. needle during cataract surgery. Whetsell v. Mutual

Life Ins. Co. of New York, 669 F.2d 955 (4th Cir.1982). But the

precise issue in that case was whether a medical treatment

exclusion clause applied. Id. at 956. The court held that the

exclusion barred the insurance claim. It observed that the clause

would be meaningless if the death were not an accident under the

policy, since “[d]eath is never caused by medical treatment absent

some misdiagnosis or mistake.” When the death results, as in the

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instant case, because proper medical treatment is unsuccessful, the

death is caused by the preexisting infirmity. See Senkier, 948

F.2d 1053. Not only does Whetsell rest on South Carolina law, it

is not inconsistent with our result. Id. at 957.

Adopting the Seventh Circuit’s analysis, we find no

principled basis on which to disassociate Mr. Thomas’s iatrogenic

injury from the disease complications of his obesity. As in

Senkier, his death was the foreseeable result of treatment for his

disease. The decision in Todd v. AIG Life Ins. Co. is

distinguishable. 47 F.3d 1338 (5th Cir.1995)(holding that an

unintended death resulting from auto-erotic asphyxiation was an

accident). The death in that case was not a foreseeable

complication of medical treatment for a disease.

In conclusion, the plan administrator did not abuse its

discretion in finding that Thomas’s injury was attributable to a

disease rather than an accident under the accidental death

policies. The judgment of the district court is AFFIRMED.

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