A case in which several patients lost their vision because of infections caused by unsanitary conditions in the preparation of their eye medicine is only one occurrence under a policy issued by a CNA Financial Corp. unit, says a federal appeals court in upholding a lower court ruling.

Wednesday’s ruling in American Casualty Co. of Reading, Pennsylvania v. Samuel Belcher et al. by the 11th U.S. Circuit Court of Appeals in Atlanta means the insurer, a unit of Chicago-based CNA Financial Corp., is obligated to pay only $1 million in coverage for a single claim rather than the possible $3 million in aggregate coverage provided by its policy.

Ophthalmologist Dr. Salomon Melgen had ordered two drugs, Avastin and Lucentis, and arranged for them to be delivered to Ocala, Florida-based Eastern Pharmacy Inc., according to the ruling.

Before they could be administered, however, Eastern Pharmacy had to repackage the drugs into single-use vials. Daoud Zayed, Eastern Pharmcy’s owner, would do that by taking vials of the medication from a refrigerator, removing the vial caps, filling single-use syringes out of the vials, and then putting the syringes into the refrigerator.

“He performed that procedure while wearing nonsterile protective gear and using nonsterile equipment, including nonsterile gloves, gowns and syringes,” said the ruling. He also repackaged the medication on top of a laminar flow hood, a bench intended to prevent cross contamination, that he never turned on, the ruling said.

Dr. Melgen used the single-use syringes to inject the drugs into the eyes of 11 people, who subsequently developed infections that resulted in partial or total vision loss. Testing determined that at least two different strains of bacteria had caused the infections, according to the ruling.

In response to complications after the injections, the U.S. Food and Drug Administration and the Florida Department of Business and Professional Regulation investigated Eastern Pharmacy and concluded that its procedure for packaging the drugs was “deficient in a number of ways.”

Lawsuits in the matter resulted in a settlement that required American Casualty to file a declaratory judgment to determine how many claims it was liable for under the health care providers professional liability insurance policy it had issued Eastern. The insurer alleged the single claim limit of $1 million applied.

The U.S. District Court in Miami agreed there was only a single claim in the case, which was unanimously upheld by the three-judge appeals court panel.

“The question is not whether there are any differences between the defendants’ individual claims,” said the ruling. “Instead, we must determine whether the claims are logically or causally connected by ‘any’ common fact, circumstance, etc. If they are, the plain meaning of the insurance policy requires that all the claims be considered a single ‘claim’ for purposes of determining the applicable liability limit.

“In this case the syringes were all prepared in the same place” and by a single person, said the ruling. “Zayed used the same process to prepare all the syringes, repeating the same violations of health and safety regulations,” the ruling said. “The syringes were all prepared for the same purpose — to be sent to Dr. Melgen to be used in treating eye problems,” said the rulng.

“In light of the myriad shared facts, cirucmstances and decisions that logically connect the defendants’ claims, it is clear that their claims arose out of ‘related acts, errors or omissions’ and because of this “the policy requires that all the defendants’ claims be considered ‘related claims,’” said the ruling in upholding the lower court ruling.

Dr. Melgen, who is not a party to the litigation, is now a co-defendant with New Jersey Sen. Robert Menendez in his corruption trial.