RW Appeal and Lawsuit Convinces MetLife to Settle Complex Accidental Death Claim
In this interesting claim on an Accidental Death and Dismemberment insurance policy, RW had the privilege of representing a widower who unexpectedly lost his wife due to an accident in the home. Shortly after midnight, our client’s wife walked into her kitchen to get a drink of water and a midnight snack. She walked into her kitchen wearing only socks, slipped on the ceramic tile floor and hit her head on the hard surface. She suffered serious and ultimately fatal brain injuries: a traumatic subarachnoid hemorrhage, subdural hematoma, brain compression, and bruising of the right temporal and frontal lobes. She was flown by emergency helicopter from her rural home to a level I trauma center. Despite the best efforts of the physicians, including the performance of an emergency craniotomy, she died as a result of her brain injuries.
Our client filed a claim for death benefits under his wife’s Accidental Death and Dismemberment insurance claim. Unexpectedly, MetLife denied the claim based on the plan’s “illness or infirmity” exclusion. The exclusion stated that MetLife will not pay benefits for a “loss” that is caused or contributed to by an illness or infirmity. MetLife claimed that the deceased had a medical condition that caused her to faint, and fainting caused her to fall. MetLife claimed two facts supported its conclusion: (1) the EMT/ambulance report noted that her fall was caused by fainting; and (2) a hospital radiologist interpreted a brain CT as showing evidence of “acute over chronic” subdural bleeding.
The RW law firm was retained by the widower to appeal MetLife’s denial. RW submitted an administrative appeal to MetLife which included nearly a decade of medical records showing that the deceased never had any history of fainting, lightheadedness, or dizziness. We interviewed every witness to the aftermath of the fall and determined that the EMTs had simply been mistaken when they documented that fainting caused the fall. They did their best in the midst of a chaotic scene where the patient was semi-conscious and combative, and with the sister of the deceased standing by hysterical while watching her sister writhing on the floor with obviously life-threatening injuries. We also interviewed the deceased’s long-time treating physician to establish there was in fact no history of fainting or light-headedness.
One complicating factor was that there were no witnesses to the fall to help determine its cause. Our client, the deceased’s husband, was in the next room when it happened. In the absence of any history of fainting or lightheadedness, it seemed much more likely to him, and to us, that the deceased had simply lost her footing reaching for a glass while wearing slippery socks on a slippery tile floor.
The medical evidence submitted with the appeal demonstrated that the deceased had no history of previous brain injury, contrary to the hospital radiologist’s interpretation of her CT scans. Mr. Warncke interviewed the neurosurgeon who had performed the deceased’s craniotomy just hours before she died. He had opened her skull and directly observed here brain, a far more comprehensive view than any MRI can afford, and much less open to interpretation. The neurosurgeon attested to the fact that the deceased did not have any chronic brain injury, but her brain was actively bleeding at the time of the CT and during surgery. He explained that on CT films active, hyperacute bleeding has the same appearance as old or “chronic” bleeding. In short, the hospital radiologist had misinterpreted new bleeding for chronic, old injury. His testimony was crucial in establishing that MetLife was clearly mistaken in concluding that any old injury had contributed to her death.
The administrative appeal heavily emphasized these medical facts, as well as the legal principles critically important to a case like this. For instance, under ERISA, the burden is on the insurer to prove that an exclusion applies. We argued that MetLife could not sustain its burden because the medical evidence simply did not support the two bases on which it had denied the claim. Another important point is that policy exclusions are interpreted narrowly.
The appeal further demonstrated that MetLife was improperly interpreting its own exclusion. As written, the exclusion applies only to “losses” caused by an illness or infirmity, not to “accidents” caused by illness or infirmity. This is an important distinction. The loss in this case was death itself. So even if the client had a condition which caused her to fall, the fainting was not the direct cause of her death. The sole cause of death was severe traumatic brain injury, as a result of the fall.
Where an illness causes a person to become dizzy or lose consciousness and then fall to their death, federal courts have long recognized this distinction and required insurers to pay accidental death benefits. For example, in a case from the nineteenth century where a man who had a pre-existing heart condition became dizzy, fell into a creek, and drowned, one court stated:
[I]f the deceased suffered death by drowning, no matter what was the cause of his falling into the water, whether disease or a slipping, the drowning, in such case, would be the proximate and sole cause of the disability or death, unless it appeared that death would have been the result, even had there been no water at hand to fall into.
RW cited this and similar cases to MetLife in the appeal.
After 90 days, MetLife had still not issued a decision on the appeal - in direct violation of the terms of the policy and of ERISA regulatory requirements. Therefore, RW filed a lawsuit on behalf of the widower. This was a strategic decision based on the law surrounding the standard of review that is given to insurance companies under ERISA. If the insurer violates the standards of “full and fair review,” which include deadlines for issuing decisions, then the insured faces an easier burden of proof in federal court.
MetLife never even filed an answer to the Complaint. The matter was quickly resolved to our client’s satisfaction and the lawsuit was dismissed.