Viera v. Life Insurance Co. of North America
642 F.3d 407
| 3rd Cir. | 2011Background
- Viera died in a 2008 head-on motorcycle crash; he was insured under an employer-provided ERISA AD&D policy issued by LINA.
- Policy defines Covered Loss and Covered Accident, and requires Proof of Loss within 90 days; it includes a Medical Condition Exclusion for illnesses or medical treatment-related causes.
- LINA denied the claim, relying on the Medical Exclusion because Coumadin (Warfarin) treatment allegedly contributed to death.
- District Court granted summary judgment to LINA, applying an abuse-of-discretion standard, and held LINA's decision was not an abuse of discretion.
- Third Circuit held the district court erred by applying abuse-of-discretion review; concluded the policy language did not clearly confer discretion, so de novo review applies and remanded for proceedings.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standard of review in ERISA denial | Viera argues for de novo review. | LINA contends discretionary review applies due to policy language. | De novo review applies. |
| Effect of 'Proof of Loss' language | Language is ambiguous and does not clearly confer discretion. | Language 'proof of loss satisfactory to Us' suggests discretion. | Language not clearly discretionary; ambiguity resolved in favor of insured; de novo review applies. |
| Medical Condition Exclusion interpretation | Last-antecedent rule and other indicia render exclusion narrower, not covering atrial fibrillation/Coumadin. | Exclusion applies because Coumadin treatment contributed to death. | District Court's interpretation upheld as correct under de novo review. |
| Ambiguity and construction canons | Ambiguity should be construed against the drafter; contra proferentem applies. | Policy language unambiguous; no contra proferentem needed. | Policy language not ambiguous; contra proferentem not applied. |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (U.S. 1989) (standard of review under ERISA—de novo unless discretionary language exists)
- Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (U.S. 2008) (abuse-of-discretion standard in ERISA cases with conflict considerations)
- Kinstler v. First Reliance Std. Life Ins. Co., 181 F.3d 243 (2d Cir. 1999) (ambiguity of 'satisfactory' language; need clear grant of discretion)
- Diaz v. Prudential Insurance Co. of America, 424 F.3d 635 (7th Cir. 2005) (safety-harbor language and deference standards; limits of 'satisfactory to us')
- Feibusch v. Integrated Device Tech., Inc., 463 F.3d 880 (9th Cir. 2006) (safe-harbor language; deference to discretion where language explicit)
- Pilosi v. JC Penney Life Ins. Co., 393 F.3d 356 (3d Cir. 2004) (canon of last-antecedent rule and contract interpretation in life insurance)