United States District Court, District of Montana, Missoula Division
FINDINGS & RECOMMENDATION
Jeremiah C. Lynch, United States Magistrate Judge
Plaintiff Dawn Rustad-Link brings this action against Defendant Metropolitan Life Insurance Company (“Metlife”) under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., seeking to recover accidental dismemberment insurance benefits she claims are due her under an employee health care plan. The parties have filed cross-motions for summary judgment on the question of whether Rustad-Link is entitled to benefits under the terms of the plan. Because Metlife did not abuse its discretion in finding that Rustad-Link’s claim was excluded from coverage, Metlife’s motion for summary judgment should be granted and Rustad-Link’s cross-motion should be denied.
In late May 2010, Rustad-Link developed a bowel obstruction and made two trips to the emergency room at St. Joseph Hospital in Ronan, Montana, with complaints of severe abdominal pain, nausea, and vomiting. (Doc. 26-6, at 1; 31-7, at 2-20). Rustad-Link made a third trip to the emergency room on May 28, 2010, at which time she was admitted to the hospital under the care of Dr. Nathaniel Buffington. (Doc. 26-6, at 1; 31-7, at 2-20). Late that night, Dr. Buffington ordered the insertion of a central femoral venous line for the purpose of administering pressor medications to support Rustad-Link’s blood pressure. (Doc. 31-7, at 13; 18-19). During the procedure, Dr. Buffington mistakenly placed an intravenous line in Rustad-Link’s right femoral artery instead of her right femoral vein, resulting in injury to the right femoral artery. (Doc. 26-6, at 1; 26-5, at 4). Dopamine, which is a pressor medication, was then infused through the line instead of intraveneously, and Rustad-Link suffered ischemia to her right lower leg. (Doc. 26-6, at 1).
Rustad-Link developed sepsis and her condition continued to deteriorate. On May 29, 2010, she was transferred to St. Patrick Hospital in Missoula, Montana, in critical condition. (Doc. 31-7, at 21; 31-8, at 3). She presented with abdominal pain and worsening sepsis. (Doc. 31-7, at 27). Rustad-Link’s doctors believed her sepsis likely had a gastrointestinal source, and performed an exploratory laparotomy to treat her small bowel obstruction. (Doc. 31-7, at 27 & 30).
On May 30, 2010, Rustad-Link’s lower right leg was noted to be extremely cool and white. An angiogram revealed a dissection flap involving the right common iliac artery with occlusion of the external iliac artery. (Doc. 31-7, at 27). Doctors placed a stent in the right external iliac artery to treat the right external iliac dissection, but it became clear over the next few days that the right lower leg was not salvageable. (Doc. 31-7, at 27). Rustad-Link developed gangrene, and on June 2, 2010, her right leg was amputated below the knee. (Doc. 31-7 at 27-28; 31-8, at 1).
At the time these events transpired, Rustad-Link was a participant in an accidental death and dismemberment plan (“the Plan”) maintained by her employer, Providence Health and Services. The Plan is an employee welfare benefit plan governed by ERISA. Providence Health and Services is the Plan Administrator. (Doc. 31-1, at 91). Metlife is the accidental death and dismemberment insurance underwriting company for the Plan, and also serves as the claims administrator. (Doc. 31-1, at 91-94). The Plan gives Metlife, as a Plan fiduciary, the “discretionary authority to interpret the terms of the Plan and to determine eligibility for an entitlement to Plan benefits in accordance with the terms of the Plan.” (Doc. 31-1, at 94).
On or about February 7, 2012, Rustad-Link submitted a claim for accidental dismemberment benefits under the Plan. (Doc. 31-6, at 1-10). Rustad-Link answered a question on the claim form asking for “a brief description of the accident” as follows: “physician inserted right femoral line. He then injected dopamine/vasoconstrictor through this line causing vascular ischemia thus resulting in gangrene and subsequent need for amputation of right lower extremity.” (Doc. 31-6, at 2).
Rustad-Link’s attending physician, Dr. Louis Kattine, also completed a written statement. (Doc. 31-6, at 4). In answer to a question asking for a description of Rustad-Link’s injuries, Dr. Kattine wrote: “Sepsis, small bowel obstruction, injury right femoral/iliac artery.” He identified “[p]erfusion of right lower extremity with pressor medication via femoral arteria line placed at St. Joseph Hospital” as a contributing cause of Rustad-Link’s loss, and stated that the cause of the amputation was “gangrene secondary to vascular occlusion.” (Doc. 31-6, at 4).
The Plan defines an accident as “[a]n unforeseen and unavoidable event resulting in an injury which is not due to any fault of the covered person.” (Doc. 31-3, at 42). Metlife denied Rustad-Link’s claim based on an exclusion for loss caused or contributed to by “physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity.” (Doc. 31-1, at 77; 31-6, at 13-15).
On March 29, 2012, Rustad-Link, through counsel, appealed MetLife’s decision and sought clarification of the denial letter. (Doc. 31-6, at 16). In response, MetLife reiterated the basis for its denial. (Doc. 31-6, at 17-18). Rustad-Link then asked that MetLife reverse it decision on the ground that her alleged loss fell within an exception to a different exclusion from coverage under the Plan. (Doc. 31-6, at 17-20).
As part of its appeal review process, MetLife obtained Rustad-Link’s complete medical records and arranged to have Dr. Elyssa Del Valle review Rustad-Link’s file. (Doc. 31-6, at 24-25; 50-51). Dr. Del Valle completed her peer review report on July 25, 2012. (Doc. 31-8, at 27-30). She concluded that the amputation of Rustad-Link’s leg “was caused by a physical illness or dissection of right common iliac artery with resultant occlusion with resultant loss of perfusion through the vessel to tissue below the occlusive site.” (Doc. 31-8, at 30).
On August 2, 2012, following its review of Dr. Del Valle’s opinion, MetLife denied Rustad-Link’s appeal and upheld its original decision denying her claim for accidental dismemberment benefits based on the exclusion for loss caused or contributed to by “physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity.” (Doc. 31-8, at 34-36). Rustad-Link requested further review, but MetLife advised her on August 25, 2012, that she had exhausted all of her appeal right under ERISA and her claim was closed. (Doc. 31-8, at 38).
In June 2013, Rustad-Link commenced this action seeking judicial review of MetLife’s decision. (Doc. 1). She alleges that MetLife breached the terms of the Plan by denying her claim for accidental dismemberment benefits, and seeks damages in the amount of unpaid benefits, prejudgment interest, and attorney fees and costs. (Doc. 1, at 13-14). The parties agree that this matter is properly ...