You Be the Judge: Dead End Appeal

A tragic accident leads to a years-long insurance dispute. How would you rule?

Statue of Justice and a stack of legal books

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On the morning of May 22, 2014, Joseph Arruda, age 57, was driving to the University of Massachusetts-Amherst to attend a work event when his car inexplicably crossed the highway median into oncoming traffic and struck another car. The collision caused Arruda’s car to hit a curb, flip over multiple times, and land upright. Though first responders performed CPR, Arruda died at the scene.

Arruda was covered for accidental death or injury under his employer’s Basic Accident Policy, issued and administered by Zurich American Insurance Company (Zurich), with his wife named as beneficiary. The terms of the policy were that Zurich would pay benefits if the loss of life was due to a covered injury, defined as “an injury directly caused by accidental means which is independent of all other causes.” The policy gave Zurich the “discretionary authority to determine eligibility for benefits and to construe the terms of the plan.”

On June 3, 2014, Mrs. Arruda filed a claim for accidental death benefits.

In response Zurich hired independent experts to gather all medical records and investigate the claim, including the medical examiner’s autopsy report that concluded the cause of death was hypertensive heart disease, with cervical spine fracture due to blunt impact as a contributory factor. Zurich denied Mrs. Arruda’s claim on the grounds that Mr. Arruda’s death was not “independent of all of causes” — was “caused by or resulted from” his pre-existing cardiac disease — and was therefore excluded under the policy.

Mrs. Arruda appealed Zurich’s determination on January 29, 2016, providing as further evidence a log book from the maker of her husband’s defibrillator implant, which monitored his heart rate and rhythm and administered electrical shocks to restore normal heart rhythm when necessary, that showed no evidence of a cardiac episode on the morning of the accident. She supplemented her appeal with reports from an independent forensic pathologist who stated, “Mr. Arruda’s correct cause of death is neck injuries due to blunt force trauma in the circumstance of a motor vehicle … collision with rollover.” She added that “the exact reason Mr. Arruda traveled across several traffic lanes and into the other vehicle is unclear,” pointing out that “only seconds of distraction or inattention to driving would be needed for his car to move out of his lane of travel. Finally, the expert questioned why Zurich had ignored the data from Arruda’s defibrillator, which showed no abnormal heart rhythms recorded prior to the collision. On May 11, 2017, Zurich’s appeals committee upheld the denial of benefits.

Mrs. Arruda appealed to the United States District Court of Massachusetts. The District judge found that Zurich’s denial was arbitrary and capricious because there was no evidence to support the conclusion that heart disease was the cause of death, other than the fact that Mr. Arruda had a history of heart disease. The judge entered judgment demanding Zurich pay Arruda’s benefit with interest.

Zurich appealed that decision to the United States Court of Appeals for the First Circuit.

How Would You Rule?

The United States Court of Appeals for the First Circuit reversed the district court, holding that Zurich’s determination that Mr. Arruda’s death was caused or contributed to by pre-existing medical conditions was supported by substantial evidence and was not arbitrary or capricious. The court explained that we must defer to administrator’s discretion where the “decision is reasonable and supported by substantial evidence on the record as a whole.”

Arruda v. Zurich American Insurance Company (2020)

This article is featured in the September/October 2021 issue of The Saturday Evening Post. Subscribe to the magazine for more art, inspiring stories, fiction, humor, and features from our archives.

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Comments

  1. This is very tragic and tricky both. What a terrible decision to have to make, but one that had to be made; like it or not. I’d have to go with the judge’s initial ruling by the District Court of Massachusetts, that Zurich pay Arruda’s benefit with interest.

    We don’t know if any findings were ‘bent’ to lean in a certain direction or not. Here though, I believe the independent forensic pathologists’s conclusions of death from blunt force trauma to the neck sustained in the course of the accident. We must look at what killed him that day, at that time. The defibrillator showed no abnormalities despite his heart problems otherwise, so no factors from that as such here.

    The awful truth is that it isn’t truly clear cut. I feel badly for his wife with her pain and suffering, but can understand how in the end it concluded legally in this manner, unfortunately.

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