Byerly v. Stnrd Ins ( 2021 )

Case: 20-40302 Document: 00515729811 Page: 1 Date Filed: 02/02/2021
United States Court of Appeals
for the Fifth Circuit United States Court of Appeals
Fifth Circuit
FILED
February 2, 2021
No. 20-40302 Lyle W. Cayce
Clerk
Sonya E. Byerly, Independent Executor of the Estate of
Gregory G. Byerly,
Plaintiff—Appellant,
versus
Standard Insurance Company,
Defendant—Appellee.
Appeal from the United States District Court
for the Eastern District of Texas
USDC No. 4:18-CV-592
Before Jolly, Southwick, and Costa, Circuit Judges.
Per Curiam:*
Gregory Byerly stubbed his toe in a household accident. Due to
several preexisting medical conditions—diabetes, peripheral neuropathy,
and peripheral arterial disease—the injury eventually required a below-the-
knee amputation of his leg. He filed a claim under his employer-sponsored
*
Pursuant to 5th Circuit Rule 47.5, the court has determined that this
opinion should not be published and is not precedent except under the limited
circumstances set forth in 5th Circuit Rule 47.5.4.
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No. 20-40302
accidental death and dismemberment (AD&D) plan. The plan administrator
rejected the claim on the ground it was not just the stubbing of his toe, but
also his preexisting conditions, that resulted in the need for an amputation.
Byerly’s wife then brought this ERISA suit on behalf of his estate (Byerly
passed away for reasons unrelated to the amputation). Concluding that there
was no qualifying “loss” even under de novo review of the claim, we
AFFIRM.
I.
Byerly worked in Texas for Fidelity National Information Services,
Inc. when he stubbed his toe. Fidelity provided its employees an AD&D
Group Policy issued by Standard Insurance Company.
The Policy provides benefits under the following conditions:
If you have an accident, including accidental exposure to
adverse conditions, while insured for AD&D Insurance, and
the accident results in a Loss, we will pay benefits according to
the terms of the Group Policy after we receive Proof Of Loss
satisfactory to us.
The Policy covers the loss of a foot, so long as the loss meets all the following
requirements:
1. Is caused solely and directly by an accident.
2. Occurs independently of all other causes.
3. With respect to Loss of life, is evidenced by a certified copy
of the death certificate.
4. With respect to all other Losses, occurs within 365 days after
the accident and is certified by a Physician in the appropriate
specialty as determined by us.
The Policy then excludes certain accidental losses. AD&D benefits
are not payable “if the accident or loss is caused or contributed to by . . .
[s]ickness . . . existing at the time of the accident” and sickness is defined as
“your sickness, illness, or disease.”
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Doctors who treated Byerly after he stubbed his toe noted the
contribution of his preexisting conditions to the pain in his toe. The doctor
Byerly visited three days after the accident diagnosed him with a toe wound
with secondary cellulitis and uncontrolled Type 1 diabetes mellitus with
peripheral neuropathy. A podiatrist diagnosed Byerly with a “diabetic foot
ulcer associated with diabetes mellitus due to underlying condition, with
necrosis of bone.” The surgeon who amputated the leg recorded that Byerly
“recently was admitted with a nonhealing left heel decubitus related to his
neuropathy and peripheral arterial disease.”
The doctors whom Standard asked to review the case reached similar
conclusions. Dr. Bergstrom concluded that “the development of infection
and gangrene was related to his current medical conditions (diabetes,
peripheral neuropathy, and [peripheral artery disease]), and likely would not
have occurred in the absence of those conditions.” Dr. Fancher, who looked
at the case after Byerly appealed the initial claim denial, found that Byerly did
“not require an amputation due to trauma alone,” concluding it “could have
only happen[ed] if he had severe underlying vascular disease, which clearly
was the case here.” In his opinion, Byerly’s “nonhealing ulcer, with
gangrene, and his need for amputation was directly related to his diabetes and
to his severe peripheral vascular disease.” Out of the hundreds of patients
Dr. Fancher has seen for foot injuries, he had “never encountered an
otherwise health[y] patient who required an amputated leg, from a simple
‘stubbed toe,’ or from any other minor foot injury or laceration.” But, he
noted, “[t]he sequence of events that happened [to Byerly] is extraordinarily
common . . . in diabetics with vascular disease.”
Based on these opinions, Standard denied Byerly’s claim. It found
that the amputation was caused, at least in part, by his diabetes and peripheral
vascular disease. As a result, his loss “did not fall within the Group Policy’s
insuring clause” because it “was not caused solely and directly by an
accident, independently of all other causes.” It also found that the exclusion
applied because Byerly’s sickness contributed to the loss.
This lawsuit followed. The district court issued a 46-page ruling
granting summary judgment to Standard. It spent much of its analysis
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discussing what standard of review applied. Although it ultimately decided
that deference was owed to the plan administrator’s determination, it also
held that it would affirm the denial of benefits even under de novo review.
II.
As we are reviewing this case at the summary judgment stage, we owe
no deference to the district court’s view of the case. Schexnayder v. Hartford
Life & Accident Ins. Co., 600 F.3d 465, 468 (5th Cir. 2010). But the parties
disagree about the underlying standard of review when a federal court
reviews the decision of an ERISA plan administrator.
The Policy grants discretion to the administrator: “Except for those
functions which the Group Policy specifically reserves to the Policyholder,
we have full and exclusive authority to control and manage the Group Policy,
to administer claims, and to interpret the Group Policy and resolve all
questions arising in the administration, interpretation, and application of the
Group Policy.” Ordinarily, that would mean we review only for abuse of
discretion. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
Plaintiff argues, however, there are two reasons why that deference is
not warranted. First, she contends that the law of Texas, where her husband
lived when he worked for Fidelity, applies rather than the law of Florida,
where Fidelity was based. That choice-of-law question might affect the
standard of review because Texas bans delegation clauses in insurance
policies, whereas Florida does not. See TEX. INS. CODE § 1701.062(a); Nat’l
Ass’n of Ins. Comm’rs, Prohibition on the Use of Discretionary Clauses Model
Act ST-42-3–6 (2020), https://content.naic.org/sites/default/files/inline-
files/MDL-042.pdf (not listing Florida among the 26 states that ban
delegation clauses); see also Ariana M. v. Humana Health Plan of Tex., Inc.,
884 F.3d 246, 256–57 (5th Cir. 2018) (en banc) (holding that de novo review
applies when a state law validly bars delegation clauses). Even if the Texas
antidelegation statute does not apply, Plaintiff argues that our deference to a
plan’s discretion is lessened because of the conflict of interest when, as here,
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the plan administrator also pays the benefits.1 See Metropolitan Life Ins. Co.
v. Glenn, 554 U.S. 105, 115–17 (2008).
But we need not wade into those issues. Even assuming arguendo that
the best possible standard for the Plaintiff—de novo review—applies, we
would not disagree with the claim denial. Covington v. Aban Offshore Ltd.,
650 F.3d 556, 558–59 (5th Cir. 2011) (providing that a choice of law analysis
is unnecessary when the application of two bodies of law leads to the same
result).
On the merits, Plaintiff does not dispute that Byerly’s comorbidities
substantially contributed to his amputation. Indeed, three separate doctors,
including Byerly’s own treating provider, stated that the gangrene and
osteomyelitis that led to the amputation would not have happened but for his
diabetes, peripheral neuropathy, and peripheral arterial disease. That would
seem to settle the issue: Byerly’s “loss” was not caused “solely and directly
by an accident” nor did it “occur independently of all other causes.”
Byerly’s underlying medical conditions, not just the accident (stubbing the
toe), contributed to the amputation.2
Although she does not dispute the consensus medical view that
Byerly’s preexisting conditions contributed to the need for an amputation,
Plaintiff argues that looking at what caused the amputation is asking the
wrong question. She contends that the focus instead should be on what
caused the “initial injury” to the toe. That would help her because the
preexisting conditions did not cause Byerly to stub his toe; stubbing the toe
was an accident. The problem for Plaintiff is that the Policy places the focus
1
This conflict-of-interest claim may be forfeited because it was not raised below.
See, e.g., Caples v. U.S. Foodservice, Inc., 444 F. App’x 49, 54 n.4 (5th Cir. 2011) (declining
to consider an administrator conflict-of-interest argument because it was not presented to
the district court).
2
For the same reason, the “sickness” exclusion also likely applies, but we need not
get to that exclusion as we find no coverage in the first place.
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not on the cause of the accident or initial injury but on the cause of the “loss.”
The loss is the amputation, so the amputation must be “caused solely and
directly by an accident” and must “[o]ccur[] independently of all other
causes.” Because neither of those two conditions are met here, the Policy
does not provide coverage.
***
We AFFIRM the judgment of the district court.
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