Abilene Texas lawyers who handle accidental death and dismemberment policy claims that are governed by ERISA, need to read this 2017, 5th Circuit Court of Appeals opinion. It is styled, Robert Ramirez v. United Of Omaha Life Insurance Company.
Ramirez traveled to West Texas and contracted a fungal infection that resulted in the removal of one of his eyes. He made a claim through the accidental death and dismemberment plan he had through his employer. The plan is governed as an ERISA plan. United of Omaha denied the claim, stating the infection that caused the removal of Ramirez’s eye was not the result of an “Accident” as that term is defined in the policy. United of Omaha was granted summary judgment by the District Court and this appeal followed.
The facts are undisputed. Following a trip to West Texas, Ramirez came in contact with a fungus and eventually was diagnosed with a condition known as coccidioidomycosis.
The policy specifies it “will not pay for any loss which … does not result from an Accident.” The policy defines Accident, Injury, and Sickness as follows:
Accident means a sudden, unexpected, unforeseeable and unintended event, independent of Sickness and all other causes.
Accident does not include Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. Accident does include bacterial infection that is the natural and foreseeable result of an accidental external bodily Injury or accidental food poisoning.
Injury means an accidental bodily injury which requires treatment by a Physician. It must result in loss independently of Sickness and other causes.
Sickness means a disease, disorder or condition, which requires treatment by a Physician.
United of Omaha denied the claim, saying “the loss of sight was not due to an Accident as defined by the policy independent of Sickness and all other causes.” Ramirez then filed suit under 29 U.S.C. Section 1132(a)(1)(B)
The policy at issue uses the term “Sickness: in three provisions pertinent to the claim: The policy states that “Accident” does not include “Sickness”; requires that an “Accident” be “independent of Sickness”; and requires that an “Injury” “result in loss independently of Sickness.” The definition of “Accident” further provides that the term does not include “disease, bodily or mental infirmity or medical treatment thereof.”
The Court concluded that under ordinary principles of contract interpretation, a fungal infection such as coccidioidomycosis falls squarely within the definition of “Sickness” and that the loss of an eye as a result of such a fungal infection is not an “Accident” within the meaning of the policy.