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Coleman v. Metropolitan Life Insurance Co.

United States District Court, E.D. North Carolina, Western Division

June 26, 2017

LINDA W. COLEMAN, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

          ORDER

          JAMES C. DEVER III Chief United States District Judge.

         On December 15, 2015, Linda W. Coleman ("plaintiff or "Linda"), having exhausted her available administrative remedies, brought this action under 29 U.S.C. § 1132(a)(1)(B) of the Employee Retirement Income Security Act ("ERISA") to recover benefits allegedly owed to her under an accidental death and dismemberment policy [D.E. 1]. On January 29, 2016, Metropolitan Life Insurance Company ("MetLife") answered the complaint [D.E. 15]. On February 22, 2016, Linda amended her complaint [D.E. 18]. On March 7, 2016, MetLife answered [D.E. 19].

         On September 30, 2016, MetLife moved for summary judgment [D.E. 24], filed an affidavit attaching the administrative record [D.E. 25], and filed a supporting memorandum [D.E. 26]. Likewise, on September 30, 2016, Linda moved for summary judgment [D.E. 27] and filed a supporting memorandum [D.E. 28]. The parties responded to each other's motions [D.E. 30, 31] and replied to those responses [D.E. 33, 34]. As explained below, the court grants Linda's motion for summary judgment, denies MetLife's motion for summary judgment, and awards plaintiff the benefits due under the policy.

         I.

         In December 2014, Linda's 86-year-old husband ("Mr. Coleman") resided at a hospice-care facility. [D.E. 25-3] 63; Administrative Record ("AR") 163. He suffered from severe dementia, significant anemia, stage-4 prostate cancer with bone metastasis, and other ailments. [D.E. 25-3] 65, 67, 69-70; AR 165, 167, 169-70. He had completed chemotherapy in March 2014, but his health had continued to decline. [D.E. 25-3] 65; AR 165. "Do Not Resuscitate" instructions were in place. [D.E. 25-3] 63, 67; AR 163, 167.

         Mr. Coleman had poor mobility and was supposed to use a wheelchair. [D.E. 25-3] 63, 65, 70; AR 163, 165, 170. On December 9, 2014, Mr. Coleman fell at his hospice-care facility. [D.E. 25-3] 63, 65; AR 163, 165. At the hospital, he was diagnosed with a hematoma and laceration on his forehead but did not suffer any intracranial damage. [D.E. 25-3] 63, 76-77; AR 163, 176-77. Imaging revealed a fracture to his left femur. [D.E. 25-3] 46, 63, 69; AR 146, 163, 169. Mr. Coleman was admitted to the hospital for the femur fracture. [D.E. 25-3] 65; AR 165.

         The treating physician determined that Mr. Coleman "was not a surgical candidate due to his multiple comorbidities, " "poor potential for healing, " and "high potential for complications." [D.E. 25-3] 65, AR 165; see [D.E. 25-3] 70; AR 170. As a result, Mr. Coleman was admitted for palliative care and made comfortable. [D.E. 25-3] 65, 67; AR 165, 167. Linda agreed that staff would not perform any additional procedures, testing, blood transfusions, or "any aggressive interventions." [D.E. 25-3] 67; AR 167; see [D.E. 25-3] 63; AR 163. The treating physician opined that Mr. Coleman would likely "require 2-3 nights for acute pain management." [D.E. 25-3] 67; AR 167.

         Around 10:30 or 11 p.m., Mr. Coleman "got acutely agitated and clinically started declining." [D.E. 25-3] 63; AR 163. He died in the early hours of December 10, 2014. Id; [D.E. 25-3] 5; AR 105.

         Sara Abbott, M.D., completed Mr. Coleman's death certificate on December 10, 2014. [D.E. 25-3] 5; AR105. She entered "accident" as the "manner of death" and made two causation-related findings. Id. She concluded that "complications of blunt force/head and hip injuries" were the "immediate cause (final disease or condition resulting in death)." Id. She listed "metastatic prostate cancer" under "other significant conditions contributing to death." Id. The following day Dr. Abbott completed an in-depth Report of Investigation, which, unlike the death certificate, listed no contributing causes in the space provided for listing them. [D.E. 25-3] 118; AR 218.

         At the time of his death, Mr. Coleman was a retired employee of Morgan Stanley. As a participant in Morgan Stanley's Employee Benefit Plan, Mr. Coleman was insured under an accidental death and dismemberment ("AD&D") policy. See Am. Compl. [D.E. 18] ¶ 6; Answer [D.E. 19] ¶ 6. The AD&D policy provides financial protection if the employee was seriously injured in an accident and suffered "dismemberment, paralysis, loss of sight, speech or hearing or loss of life." [D.E. 25-1] 104; AR 528. The AD&D policy covers all accidents except those listed as exclusions. Id. In relevant part, the exclusions provide that:

No payment will be made for any Loss if it results from or is caused or contributed to by:
* * *
• Sickness, disease, bodily or mental infirmity or medical or surgical treatment, bacterial or viral infection, regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning.
Note: These are accident-only policies. The Basic and AD&D Insurance Plans do 1 not pay benefits for losses caused by or resulting from illness, disease or bodily infirmity, as determined by MetLife.

[D.E. 25-1] 108-09; AR 532-33.

         MetLife acts as both the reviewer and administrator of AD&D claims. [D.E. 25-1] 148, 164; AR 572, 588. If covered, a death resulting from an accident requires MetLife to pay Mr. Coleman's beneficiary-Linda-$1, 050, 000.00. [D.E. 25-3] 323, 325; AR 423, 425.

         On December 22, 2014, Linda submitted a claim with MetLife. [D.E. 25-3] 2-3; AR 102-03. On December 23, 2014, MetLife acknowledged Linda's claim and asked Linda to send additional documentation so it could determine whether she was entitled to AD&D benefits. [D.E. 25-3] 10; AR 110. Linda sent MetLife the requested information. See [D.E. 25-3] 7-9; AR 107-09.

         On March 24, 2015, MetLife notified Linda that it would deny her claim. [D.E. 25-3] 85-87; AR 185-87 ("First Denial Letter"). After quoting portions of the AD&D coverage provisions, the First Denial Letter stated:

         The Plan further states on pages 106-107:

No payment will be made for any Loss if it results from or is caused or contributed to by:
• Sickness, disease, bodily or mental infirmity or medical or surgical treatment, bacterial or viral infection, regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental eternal bodily injury or accidental food poisoning.
According to our records, the Certificate of Death issued in the State of North Carolina for William Coleman states his cause of death as "Complications of blunt force/head and hip injuries" and his manner of death as "Accident." The death certificate lists metastatic prostate cancer as a contributing condition. According to the WakeMed Cary Emergency Services William had gotten up to use the bathroom however was not using his wheelchair and fell. William had prostate cancer with bone metastasis. As a medical condition contributed to the death, Accidental Death benefits are not covered under the terms of the Plan.
Therefore, based on the record before MetLife, we must deny your claim. Under ERISA, you have the right to appeal this decision within sixty (60) days after the receipt of this letter.

[D.E.25-3]86;AR186.

         After receiving the First Denial Letter, Linda, through counsel, requested and received an extension of time within which to appeal the decision. See [D.E. 25-3] 104; AR 204. On June 29, 2015, Linda filed her appeal. [D.E. 25-3] 107-09; AR 207-09. Linda contended that:

MetLife improperly considered [Mr. Coleman's] metastatic prostate cancer as a contributing cause of death under the above accidental death policy. The governing legal standard applied by courts for evaluating whether a preexisting illness may preclude coverage under an accidental death policy is as follows:
[A] pre-existing infirmity or disease is not to be considered as a cause unless it substantially contributed to the disability or loss .... [A] 'predisposition' or 'susceptibility' to injury, whether it results from congenital weakness or from previous illness or injury, does not necessarily amount to a substantial contributing cause. A mere 'relationship' of undetermined degree is not enough. Adkins v Reliance Standard Life Ins Co, 917 F.2d 794, 797 (4th Cir. 1990) (quoting Colonial Life & Ace Ins Co v Weartz, 636 S.W.2d 891, 894 (Ky. Ct App 1982) (emphasis added)Q.]

[D.E. 25-3] 107; AR 207. Although the death certificate listed "metastatic prostate cancer" under "other significant conditions contributing to death, " Linda contended that "there is no indication that Mr. Coleman's cancer substantially contributed to his death on December 10 as required by the applicable legal standard." [D.E. 25-3] 108; AR 208. Linda argued that "[t]he listing of Mr. Coleman's metastatic prostate cancer on the Certificate of Death shows only a mere relationship of undermined degree which does not satisfy the legal standard applicable to accidental death benefits." Id. (quotation omitted).

         Linda's appeal included a "Report of Investigation" that Dr. Abbott completed on December 11, 2014. [D.E.25-3] ¶ 8;AR2I8. It lists the "probable cause of death" as "complications of blunt force head and hip injuries due to fall from standing." Id. But unlike the death certificate, it lists no contributing causes in the space provided to list them. Id. Linda's appeal also recounted a telephone conversation between Linda's counsel and Dr. Abbott in which Dr. Abbott said:

• In her medical opinion, "Mr. Coleman would not have died at the time he did but for the accidental fall and traumatic injuries he suffered as a result."
• She listed "'complications of blunt force head and hip injuries' as the 'Immediate Cause' of death" on the death certificate "because Mr. Coleman's injuries from the accidental fall were the immediately precipitating event or condition causing his death."
• She listed "metastatic prostate cancer" in the box labeled "other significant conditions contributing to death" "only because decreased mobility due to prostate cancer may have contributed to Mr. Coleman's accidental fall; however, the prostate cancer was not the 'Immediate Cause' of death."

Id. (emphasis in original). Linda requested that "MetLife review its denial of coverage under the applicable legal standard." [D.E. 25-3] 109; AR 209.

         On appeal, MetLife sought the opinions of Derrick Bailey, M.D., one of MetLife's in-house doctors. [D.E. 25-3] 274-75; AR 3 74-75.[1] The questionnaire solicited the following responses from Dr. Bailey:

#2: Can you, within a reasonable degree of medical certainty, determine whether an otherwise healthy person would have died from the injuries sustained in the fall? [ ]YES [ ]NO
It seems unlikely that an otherwise healthy person would have died from the fall. The insured had a fall from standing in which he may have struck his head and sustained a fracture of his left femur. Femur fractures from such an injury usually happen only in older individuals or those with bone disease such as osteoporosis (more common on older individuals). Injuries of this kind are associated with significant morbidity and mortality because they tend to occur in less healthy and hearty individuals. The insured did not have a significant intracranial injury from this fall though he had evidence of prior strokes. Besides being of advanced age with evidence of strokes in the past the insured also had metastatic prostatic cancer making him even more susceptible to unfavorable outcome in case of an adverse event (such as the fall).
#3: Can you, within a reasonable degree of medical certainty, determine whether the loss was caused by an illness? [ ]YES [ ]NO
The insured's underlying condition very likely contributed to the outcome, compounding the insult to the fall.
#4: As the medical records provided show that the insured had a medical condition, to a reasonable degree of medical certainty, can you determine whether this medical condition caused or contributed to the death? [ ]YES [ ]NO It is likely the medical condition contributed to the outcome as noted above.
#5: In your medical opinion, can you determine whether or not an otherwise healthy person would have passed away from the fall that the decedent suffered? [ ] Yes []No
It is unlikely that an otherwise healthy person would have passed away from the injury of a fracture of the proximal femur.

[D.E. 25-3] 277-78; AR 377-78 (citation omitted).

         In summarizing the details of the claim on appeal, MetLife's analyst stated that Linda's attorney "cites some case law but they appear to be state cases, not federal; this is an ERISA regulated benefit" and that in Dr. Bailey's opinion Mr. Coleman's "medical conditions contributed to bis death." [D.E. 25-3] 280; AR 380.

         On August 7, 2015, MetLife notified Linda by letter that it had considered her appeal and concluded that it had properly denied the claim. [D.E. 25-3] 283-85; AR 383-85 ("Second Denial Letter"). ...


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