Employee Retirement Income Security Act (ERISA). These cases are tough even under the best of circumstances. Lawyers who handle ERISA cases do not spend time advertising their great results. The reason is the ERISA law prohibits “great” results. A win is just getting what you should have received in the first place. But wins are few and far between, especially in the United States Fifth Circuit.
Here is a case from the Northern District of Texas, Wichita Falls Division. It’s styled is, Edythe Koch v. Metropolitan Life Insurance Company.
In this case, the Court denied MetLife’s motion for summary judgment which is unusual in these cases, thus, at first blush one thinks a win is coming. But when the Judge conducted it’s own review of the record, the Court upheld the plan administrator’s denial of accidental life insurance benefits.
Following the unexpected death of her husband, Mrs. Koch filed a claim for accidental death benefits under her ERISA Plan. To support her claim that Mr. Koch died as a result of an “accidental injury,” Mrs. Koch submitted several documents, including Mr. Koch’s “death certificate, the Employer’s Statement, a letter from an attorney for Mrs. Koch, a letter from the medical examiner, a toxicology report, and documents from the hospital.” These documents—along with the Plan and the summary plan description, the parties’ correspondence, and other medical records Mrs. Koch supplied upon MetLife’s request—ultimately comprise the 541-page administrative record. Though Mrs. Koch contended that her husband “died accidentally” after he “suffered a fall while getting out of bed, causing damage to his neck resulting in his death,” MetLife reviewed the medical records, concluded that the death was “natural,” and twice denied Mrs. Koch’s claim.
The case needs to be read by all ERISA lawyers. There is a discussion about the way the word accident is used in the policy. However, the Court presumes a definition in favor of Mrs. Koch but then turns against her by referencing the words in the policy which say “if [she] or [her] Dependent sustains an accidental injury that is the Direct and Sole Cause of a Covered Loss.” “Direct and Sole Cause means that the Covered Loss . . . was a direct result of the accidental injury, independent of other causes.” Additionally, the Plan specifically states that MetLife “will not pay benefits . . . for any loss caused or contributed to by: (1) physical or mental illness or infirmity, or the diagnose or treatment of such illness or infirmity.” The Plan also places the burden on the policyholder to submit “Proof of the accidental injury and Covered Loss.”
In rendering it’s decision the Judge wrote, Fortunately, the resolution of this case need not hinge on the meaning of “accident.”
When the Court reviews the administrator’s decision de novo—just as when the administrator reviews the initial claim—the claimant “bears the burden of proving by a preponderance of the evidence” that she is entitled to benefits. Here, the administrative record contains evidence pointing both directions—some records suggest that the fall caused Mr. Koch’s death, while others suggest Mr. Koch died of a heart attack. For example, there is conflicting evidence regarding where he fell. Was it in the bathroom, as Mrs. Koch’s attorney initially asserted;while getting out of bed, as the EMS report stated; or somewhere in between, as another EMT reported? And regardless, it is unclear when the heart attack occurred and whether it caused the fall or vice versa. Or was the death “natural”?
The record leaves many questions unanswered. But one thing is clear: Mrs. Koch, the party required to prove her claim by a preponderance of the evidence, cannot point to a single piece of evidence in the administrative record that proves the fall was the sole cause. At most, she can prove that some evidence suggests potential causation between Mr. Koch’s fall and his subsequent death. Accordingly, Mrs. Koch has not carried the burden of establishing that Mr. Koch’s fall was the direct and sole cause of his death.
The Court ruled in favor or MetLife.