Court Finds SPD Created Expectations of Benefits

In its opinion, the court noted that, although Robert Weis had an eye disease since birth, he had partial vision in his left eye until an accident which caused him to poke his eye. A doctor’s note stated the pre-existing condition did not likely contribute to Weis’ injury.

The court found that the SPD had determined Weis’ reasonable expectations for benefits. Weis was not provided with a plan document, according to the opinion. The court noted, if language in the SPD could create different expectations than language of the document, the language most favorable to the plaintiff controls.

Weis was a participant in the Accidental Death & Dismemberment Benefit Plan of Kaiser Foundation Health Plan, Inc. The policy defined “injury” as “bodily injury caused by an accident . . . and resulting directly and independently of all other causes in a covered loss,” according to the court opinion. The policy excluded “any loss caused in whole or in part, or resulting in whole or in part from, . . . sickness, disease or infections of any kind.” The SPD more generously stated that “Accidental Death and Dismemberment benefits are not payable for death and dismemberment due to: most natural illnesses or diseases.”

Weis was born with congenital cataracts and surgery at age five left him with partial vision in his left eye, the court opinion said. Thirty years later Weis tripped and fell in his home and poked his thumb into his left eye. He was diagnosed with a severely detached retina.

Weis underwent surgery to repair the retina and, though he initially regained his pre-existing limited vision, complications from the surgery caused him to lose total vision in his left eye. He applied for benefits from his AD&D plan, and his claim was denied.

The case is Weis II v. Accidental Death & Dismemberment Benefit Plan of Kaiser Foundation Health Plan Inc.