Coleman v. Metro. Life Ins. Co., 5:15–CV–654–D
Citation | 262 F.Supp.3d 295 |
Decision Date | 26 June 2017 |
Docket Number | No. 5:15–CV–654–D,5:15–CV–654–D |
Court | U.S. District Court — Eastern District of North Carolina |
Parties | Linda W. COLEMAN, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant. |
Jessica Blair Vickers, Michael T. Medford, Manning Fulton & Skinner, P.A., Raleigh, NC, for Plaintiff.
Elizabeth J. Bondurant, Womble Carlyle Sandridge & Rice, PLLC, Atlanta, GA, Katherine T. Lange, Womble Carlyle Sandridge & Rice, LLP, Charlotte, NC, for Defendant.
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.
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.
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:
[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:
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; AR 186.
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 & Acc Ins Co. v. Weartz , 636 S.W.2d 891, 894 (Ky. Ct. App. 1982) (emphasis added) [ ).]
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] 118; AR 218. 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:
To continue reading
Request your trial-
Dowdy v. Metro. Life Ins. Co.
...factor was more than merely related to the injury, and was instead a substantial catalyst. See, e.g. , Coleman v. Metro. Life Ins. Co. , 262 F.Supp.3d 295, 312 (E.D.N.C. 2017) (finding against a defendant in an ERISA case where "the record contains no indication that [the plaintiff's] cance......
- Sanders v. Vigor Fab, LLC
-
Ramirez v. Liberty Life Assurance Co. of Bos.
...influenced its decisionmaking process and conclusions," then that consideration weighs against remand. Coleman v. Metropolitan Life Ins. Co., 262 F. Supp. 3d 295, 316 (E.D.N.C. 2017). Here, remanding the case would be a useless formality. Liberty's filereviewers conducted a "full file revie......
- Price v. Atl. Ro-Ro Carriers, Inc.