U.S. Court of Appeals Overturns Summary Judgment in Favor of Health Insurer Over Death Following Surgery

The U.S. Court of Appeals for the 7th Circuit in Chicago has overturned a summary judgment order that was entered by a U.S. District Court judge over whether an insurance company, Sun Life & Health Insurance Co. (U.S.), should pay death benefits to the husband of the plaintiff when he died after tearing his left Achilles tendon.

Sun Life had moved for summary judgment claiming it was not responsible for paying the $92,000 death benefit to Lee Ann Prather, the wife of the decedent, Jeremy Prather. Prather injured his Achilles tendon while playing basketball. About two weeks after his surgery to repair the tendon, he died at age 31. A blood clot, or deep vein thrombosis (DVT) developed in his injured leg and had broken loose and traveled to his lung. The clot or pulmonary embolism caused cardiac arrest and his subsequent death.

Sun Life declined to pay the $92,000 benefit on the ground that Prather’s injury on the basketball court was not the sole cause of his death. Instead, Sun Life argued that the surgery that Prather underwent following the injury was a contributing factor to his death.

The 7th Circuit held that Sun Life had not proved its case.

The only medical evidence Sun Life presented was the opinion of a physician’s assistant that Prather faced an increased risk of a blood clot as result of the surgery or even as a result of the immobilization of his leg after he tore the tendon.

That evidence, Judge Richard A. Posner, writing for the court of appeals panel that “was inconclusive.”

The opinion from the physician’s assistant demonstrated only that the surgery might have been a partial cause of Prather’s death, Judge Posner wrote – “partial because the accident had to have played a role; no accident, no surgery or immobilization, hence no deep vein thrombosis or pulmonary embolism.”

The court of appeals also rejected the argument that under the insurance policy obtained by Prather’s employer, Sun Life had discretion to determine what evidence was enough to demonstrate coverage. Judge Posner wrote that such a holding “would amount to the insurer’s having cart blanche to decide whether or not to honor its contract.”

Having reversed the district court judge, the case was sent back to the district court in the Central District of Illinois with instructions to enter judgment in favor of Lee Ann Prather.

Representing the Prather family was Mark D. DeBofsky who argued the case before the U.S. 7th Circuit Court of Appeals.

Lee Ann Prather v. Sun Life & Health Insurance Co. (U.S.), No. 16-1861 (U.S. Court of Appeals for the 7th Circuit).

Kreisman Law Offices has been handling wrongful death lawsuits, catastrophic injury cases, medical negligence cases, birth trauma injury cases and truck accident cases for individuals and families who have been injured or killed by the negligence of another for more than 40 years, in and around Chicago, Cook County and surrounding areas, including Morton Grove, Kenilworth, Richton Park, Highwood, Homewood, Arlington Heights, Deerfield, Wheaton, Wheeling, Aurora, Worth, Chicago (Lincoln Park, Lincoln Square, Bucktown, Wicker Park, Logan Square, East Side), Gurnee and Crystal Lake, Ill.