Tupufia Faamai v. Metropolitan Life Insurance Co

FILED
NOT FOR PUBLICATION JAN 04 2013
MOLLY C. DWYER, CLERK
UNITED STATES COURT OF APPEALS U.S. COURT OF APPEALS
FOR THE NINTH CIRCUIT
TUPUFIA FAAMAI, No. 11-55591
Plaintiff - Appellant, D.C. No. 2:10-cv-00547-GHK-E
v.
MEMORANDUM*
METROPOLITAN LIFE INSURANCE
COMPANY,
Defendant - Appellee.
Appeal from the United States District Court
for the Central District of California
George H. King, Chief District Judge, Presiding
Submitted December 4, 2012**
Pasadena, California
Before: PREGERSON, NOONAN, and PAEZ, Circuit Judges.
Plaintiff-Appellant Tufupia Faamai (“Faamai”) appeals the district court’s
order dismissing with prejudice his ERISA action to recover accidental death
*
This disposition is not appropriate for publication and is not precedent
except as provided by 9th Cir. R. 36-3.
**
The panel unanimously concludes this case is suitable for decision
without oral argument. See Fed. R. App. P. 34(a)(2).
benefits for the death of his wife, Melisa Tuitasi Faamai (“Mrs. Faamai”). Mrs.
Faamai died after undergoing gastric bypass surgery. We have jurisdiction
pursuant to 28 U.S.C. §1291, and we affirm.
We review for abuse of discretion Defendant-Appellee Metropolitan Life
Insurance Company’s (“Met Life”) denial of Faamai’s claim for accidental death
benefits. Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 965 (9th Cir. 2006).
The district court dismissed Faamai’s claim with prejudice because it found that
Met Life did not abuse its discretion in denying accidental death coverage based on
two exclusions listed in Mrs. Faamai’s accidental death and dismemberment
insurance policy. The exclusions were for deaths caused by: (1) the treatment of
an “illness or infirmity,” and (2) “infection, other than [an] infection occurring in
an external accidental wound.”
1. Met Life excluded Mrs. Faamai’s death from accidental death coverage because
it classified obesity as a “physical or mental illness or infirmity,” and gastric
bypass surgery as “treatment of such illness or infirmity.” This exclusion applies
only if obesity is classified as an illness or infirmity, an issue that we need not
reach to affirm the district court’s dismissal.
2. Met Life also barred Faamai’s recovery of accidental death benefits on the basis
that Mrs. Faamai’s death was “caused or contributed to by an infection, other than
2
[an] infection occurring in an external accidental wound.” Pursuant to this
exclusion, an infection occurring in either an internal wound or a non-accidental
external wound is excluded from coverage.
Here, a suture came loose following Mrs. Faamai’s gastric bypass surgery.
This resulted in a peritoneal leak from the staple line on the gastric remnant. The
peritoneum is the thin layer of irregular connective tissue that lines the abdominal
cavity. STEDMANS MEDICAL DICTIONARY 1333 (26th ed. 1995). The gastric
remnant is the stomach’s “residue or vestige.” Id. at 707, 1526. The undone suture
on Mrs. Faamai’s stomach resulted in an internal leak that caused sepsis.1 Then
Mrs. Faamai died. In light of these circumstances, Met Life reasonably determined
that Mrs. Faami's death was caused or contributed to by an infection that did not
result from an accidental external wound,2 and therefore her husband, Faamai, is
not entitled to recover accidental death benefits under the terms of the policy.
1
Sepsis is defined as “[t]he presence of various puss forming and other
pathogenic organisms, or their toxins, in the blood or tissues.” STEDMANS
MEDICAL DICTIONARY 1598 (26th ed. 1995).
2
Contra Unified W. Grocers, Inc. v. Twin City Fire Ins. Co., 457 F.3d 1106,
1116 (9th Cir. 2006) (citing AIU Ins. Co. v. Superior Court, 51 Cal.3d 807, 822
(Cal. 1990)) (“If ambiguities remain” after construing the ambiguous language in
the “‘context of the instrument as a whole[,]’” [Bank of the W. v. Superior Court, 2
Cal.4th 1254, 1264-65 (Cal. 1992),] “then these ambiguous terms are construed
against the insured and in favor of coverage.”)
3
We AFFIRM the district court’s dismissal of Faamai’s claim with prejudice.
4