Home > Blog > Blog > Accidental Death Benefits > Fifth Circuit Holds That Death Caused By Mishap During Insured’s Self-Treatment Falls Under Accidental Death Policy’s Medical Treatment Exclusion

Fifth Circuit Holds That Death Caused By Mishap During Insured’s Self-Treatment Falls Under Accidental Death Policy’s Medical Treatment Exclusion

In Lebron v. National Union Fire Insurance Company of Pittsburgh, Pennsylvania, et al., No. 20-20165, __F.App’x__, 2021 WL 1396574 (5th Cir. Apr. 13, 2021), the Fifth Circuit was tasked with deciding whether a death fell under an ERISA-governed accidental death insurance policy’s exclusion for losses caused by “medical or surgical treatment.” In this case, the insured, Barbara, was diagnosed with end-stage renal disease associated with hypertensive cardiovascular disease, which required regular dialysis treatment. She took a blood thinner due to issues she had with blood clotting during dialysis treatment. Unfortunately, Barbara bled to death after she accidentally cut her dialysis catheter with scissors while changing a bandage around the catheter. Investigators ruled her death an accident. The medical examiner concluded that her death was caused by “exsanguination [severe loss of blood] from cut dialysis catheter placed for treatment of end-stage renal disease associated with hypertensive cardiovascular disease.” Two doctors opined that her death was an accident not attributable to an expected medical complication. Nonetheless, Defendant denied payment of accidental death benefits because it determined that the injury did not result directly and independently of all other causes in her death.

The district court applied de novo review and granted judgment to Defendant. Plaintiff appealed the district court’s determination of the merits and Defendant appealed the district court’s application of de novo review rather than abuse of discretion review. The Fifth Circuit declined to decide the standard of review issue because it found that Defendant would prevail under either standard of review.

On the merits, the issue for the Fifth Circuit is “whether Barbara’s actions in changing a bandage around her dialysis catheter constitute ‘medical or surgical treatment,’ which the Policy excludes from coverage.” In resolving this question, the court noted that the Policy does not define “medical or surgical treatment” but that “medical treatment” is unambiguous and has a generally accepted meaning which the court is bound to apply. Webster’s Third New International Dictionary defines “medical treatment” as “the action or manner of treating a patient medically or surgically,” and to “treat” is “to care for (as a patient or part of the body) medically.” Black’s Law Dictionary defines the word “treatment” as a “broad term covering all the steps taken to affect a cure of an injury or disease; including examination and diagnosis as well as application of remedies.”

The court found that Barbara’s actions in changing the bandages around her dialysis catheter fall under this broad term because they were facilitating treatment for her disease. The court rejected the argument that the term is ambiguous because it is normally understood to encompass what a doctor does to a patient. The court found that under the caselaw, the phrase does not depend on who is providing the treatment. Further, courts uniformly apply the medical treatment exclusion where an accidental mishap during treatment causes death. “Because the term ‘medical or surgical treatment’ unambiguously covers Barbara’s actions in changing her bandages in preparation for an upcoming dialysis treatment, there is no genuine issue of material fact that the Policy does not cover Barbara’s death.” The court affirmed the district court’s judgment.


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*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.

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