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.