The Bar Association of the Fifth Federal Circuit’s (BAFFC) goal is to improve and facilitate the administration of justice in the federal courts within the Fifth Circuit. Thousands of attorneys committed to raising the standards of proficiency and integrity in federal practice have joined our Association.
As an attorney in good standing with the bar of any American state or territory, you are eligible to become a member of the Bar Association of the Fifth Federal Circuit.
Before SMITH, OWEN, and HIGGINSON, Circuit Judges.
AFFIRMED. (October 6, 2017).
Posted in ERISA, Insurance
Robert Ramirez traveled to West Texas and contracted a fungal infection (coccidioidomycosis) in his right eye that ultimately resulted in its removal. He sought benefits under an accidental death and dismemberment and life insurance policy provided by his employer and subject to the Employee Retirement Income Security Act. The insurer, United of Omaha Life Insurance Company, denied the claim, stating in part that “the loss of sight was not due to an Accident as defined by the policy independent of Sickness and all other causes.” Ramirez filed an administrative appeal, and United upheld the claim denial. Ramirez then filed the underlying suit. The policy provided that “[t]he [Accidental Death and Dismemberment] Benefit is paid if an employee is injured as a result of an Accident, and that Injury is independent of Sickness and all other causes.” The policy specified that it “will not pay for any loss which  does not result from an Accident.” The District Court granted summary judgment in favor of United, holding that Ramirez’s infection did not qualify as an “Accident” within the meaning of the policy. Ramirez appealed. Applying ordinary principles of contract interpretation, the Fifth Circuit affirms the District Court’s grant of summary judgment for United. The Court holds that coccidioidomycosis is not an “Accident” within the meaning of the policy. The Court reasons that Ramirez’s loss of sight from coccidioidomycosis is not “independent of Sickness,” and thus is not covered by the policy. The Court further explains that the policy’s extension of coverage does not turn on whether the death or loss was caused by a condition that arose after the inception of the policy. Rather, the Court stresses that the nature and cause of the loss are the determinative factors of coverage.
On Appeal from the United States District Court for the Northern District of Texas (Sam R. Cummings).
Attorney for Appellant – Robert E. Goodman, Jr., Dallas, TX
Attorney for Appellee – Linda Patricia Wills, Houston, TX
Read more by signing up for the FREE commentary on the decision of the week!