Robert Ramirez v. United of Omaha Life Ins Co., 872 F.3d 721

Robert Ramirez, an MS International employee, traveled to West Texas in November 2013 and subsequently contracted coccidioidomycosis (valley fever).
Medical evidence (assumed for summary judgment) attributed the infection to inhalation of Coccidioides spores on work trips and it ultimately led to removal of his right eye in October 2014.
Ramirez sought Accidental Death & Dismemberment (AD&D) benefits under his employer’s ERISA plan, insured by United of Omaha Life Insurance Co. (United).
The policy pays AD&D benefits only when loss results from an “Accident,” defined as a “sudden, unexpected, unforeseeable and unintended event” and excluding “Sickness,” disease, and “bacterial or viral infection, regardless of how contracted.”
United denied the claim, concluding the eye loss resulted from a “Sickness” (fungal disease) and therefore was not an “Accident”; denial upheld on administrative appeal and Ramirez sued under 29 U.S.C. § 1132(a)(1)(B).
The district court granted summary judgment for United; the Fifth Circuit affirmed, applying de novo review and interpreting the policy under federal common law.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether coccidioidomycosis is a “Sickness” excluded from the policy’s definition of Accident	Ramirez: fungal infection is not a “Sickness” for policy purposes and thus is an Accident	United: coccidioidomycosis is a disease/disorder requiring physician treatment and fits the policy’s definition of Sickness	Held: Infection is a “Sickness” and excluded from Accident coverage
Whether a fungal infection can be treated as an “Accident” because policy only names bacterial/viral infections as excluded	Ramirez: omission of “fungal” implies fungal infections are covered as Accidents; analogous to accidental food poisoning	United: other terms (Sickness, disease, infirmity) encompass fungal infection; carve‑back for bacterial infection and food poisoning is limited	Held: Policy unambiguously excludes fungal infection; carve‑back does not extend to fungal infections
Whether contra proferentem or insurer‑deference alters interpretation	Ramirez: ambiguous terms should be construed against insurer	United: terms are unambiguous under ordinary meaning	Held: Terms unambiguous; contra proferentem not applied; ordinary contract interpretation controls

Cooper v. Hewlett-Packard Co., 592 F.3d 645 (5th Cir. 2009) (summary judgment principles in ERISA cases)
Green v. Life Ins. Co. of N. Am., 754 F.3d 324 (5th Cir. 2014) (use ordinary meaning for ERISA plan terms)
Wegner v. Standard Ins. Co., 129 F.3d 814 (5th Cir. 1997) (contra proferentem and plan‑interpretation principles)
Int’l Ins. Co. v. RSR Corp., 426 F.3d 281 (5th Cir. 2005) (questions of contract ambiguity decided by court)