Kellogg v. Metropolitan Life Ins. Co.

Decision Date04 December 2008
Docket NumberNo. 07-4213.,07-4213.
Citation549 F.3d 818
PartiesCherilyn KELLOGG, now known as Cherilyn Worsley, Plaintiff-Appellant, v. METROPOLITAN LIFE INSURANCE CO.; Pfizer Accidental Death and Dismemberment Insurance Plan, Defendants-Appellees.
CourtU.S. Court of Appeals — Tenth Circuit

Brian S. King (James L. Harris, Jr. with him on the briefs), Salt Lake City, UT, for Plaintiff-Appellant.

Jack M. Englert, Jr. (James L. Barnett, Holland & Hart LLP, Salt Lake City, UT, with him on the brief), of Holland & Hart LLP, Greenwood Village, CO, for Defendants-Appellees.

Before BRISCOE, SEYMOUR, and PORFILIO, Circuit Judges.

BRISCOE, Circuit Judge.

Plaintiff Cherilyn Kellogg brought this action against defendants Metropolitan Life Insurance Company and Pfizer Accidental Death and Dismemberment Insurance Plan, claiming she was wrongly denied accidental death and dismemberment benefits under an employee welfare benefit plan regulated by the Employee Retirement Income Security Act of 1974 (ERISA), as amended, 29 U.S.C. §§ 1001-1461. Cherilyn Kellogg's deceased husband, Brad Kellogg, was a participant in the plan at issue. On the parties' cross-motions for summary judgment, the district court granted judgment in favor of the defendants. Kellogg now appeals the district court's decision. Exercising jurisdiction pursuant to 28 U.S.C. § 1291, we reverse the district court's grant of summary judgment in favor of defendants and remand with directions to enter summary judgment in favor of Kellogg. We also direct the district court, on remand, to consider Kellogg's requests for fees and prejudgment interest.

I.

Brad Kellogg's fatal accident

On September 6, 2004, Brad Kellogg was driving a 1993 Dodge Caravan eastbound on East Alexander Avenue in Merced, California. He purportedly stopped at a stop sign at the intersection of East Alexander Avenue and Parsons Avenue, and then continued eastbound on East Alexander Avenue. As he proceeded eastbound, his minivan veered into the westbound lane, and then into a tree on the north side of East Alexander Avenue. A female resident who observed the crash called 911. Law enforcement and fire officials responded to the scene and found Brad Kellogg "hunched over in the driver's seat" of the minivan, "incoherent and bleeding from his face." App. at 170. After being extracted from his vehicle, Brad Kellogg was transported to a local hospital, where he died.

The woman who observed the crash and called 911 was questioned by a law enforcement officer and stated

that she had seen the vehicle with the subject in it make the stop eastbound on E. Alexander at Parsons. [She] said that once the vehicle had taken off from the stop sign at Parsons, that she noticed that the driver appeared to be having a seizure. [She] said that the vehicle then veered into the tree on the northside of E. Alexander. [She] said that she noticed the subject did not even step on his brakes, as she did not see the brake lights, nor did she hear a skid.

Id.

On September 10, 2004, the Merced County (California) Sheriff's Department received a toxicology report that indicated that Brad Kellogg, at the time of his death, had detectable levels of five prescription and/or over-the-counter drugs in his system: acetaminophen (2.2mg/L), buproprion (2.29 mg/L), hydrocodone (0.23 mg/L), propoxyphene (0.08 mg/L), and norpropoxyphene (0.12mg/L).

On September 13, 2004, an autopsy report was prepared by a private pathologist for the Merced County Sheriff's Department Coroner's Division. The report's "CASE SUMMARY" section read as follows:

The cause of death in this case is considered to be extensive subarachnoid hemorrhage of the brain secondary to traumatic transverse basilar skull fracture. Post mortem toxicology studies revealed effective levels of acetaminophen, hydrocodone, propoxyphene, and Norpropoxyphene. Levels of Bupropion far exceed therapeutic levels in this patient. Idiosyncratic reactions of this drug include: numerous neuropsychiatric phenomenon including psychoses, confusion, delusion, hallucinations, psychotic episodes, and paranoia. Whether excessive levels of this drug contributed to this subject's accidental and [sic] death is unknown.

Id. at 190.

On January 20, 2005, the Deputy Coroner for Merced County signed a "Physician/Coroner's Amendment." Id. at 85. That document indicated that Brad Kellogg suffered a "SUBARACHNOID HEMORRHAGE" and a "BASILAR SKULL FRACTURE" from a "SOLO MOTOR VEHICLE ACCIDENT." Id. The document further stated as follows:

THE DECEDENT WAS THE SAFETY BELT RESTRAINED DRIVER AND SOLE OCCUPANT OF A DODGE CARAVAN THAT HE WAS DRIVING EASTBOUND ON ALEXANDER AVENUE. THE DECEDENT COMPLETED A STOP AT THE POSTED STOP SIGN AT THE INTERSECTION OF PARSONS AVENUE. HE THEN AGAIN PROCEEDED EASTBOUND AND AT THAT POINT, ACCORDING TO A WITNESS HE APPEARED TO HAVE A SEIZURE, LOST CONTROL OF THE VEHICLE AND RAN HEADON [sic] INTO A TREE LOCATED NEXT TO THE CURB OF THE WESTBOUND LANE OF ALEXANDER. THE DECEDENT

HAD A POST MORTEM BLOOD BUPROPION LEVEL OF 2.29 MG/L. THIS DRUG HAS A REPORTED RISK FACTOR OF SEIZURES.

Id.

Brad Kellogg's coverage under the Plan

At the time of his death, Brad Kellogg was employed by Pfizer Incorporated (Pfizer) as a pharmaceutical sales representative and was a participant in the Pfizer Life Insurance and Accidental Death and Dismemberment (AD & D) Insurance Plans (the Plan), which was an ERISA-regulated employee welfare benefit plan. The Plan automatically provided each participant life insurance coverage equal to two times their annual pay. The Plan further allowed each participant the opportunity to elect additional life insurance coverage and one of ten AD & D insurance coverage options. Brad Kellogg elected to pay for additional life insurance and AD & D coverage in amounts equal to "six times [his] annual pay," or approximately $438,000.00 each. Id. at 63.

The AD & D provisions of the Certificate of Insurance provided, in pertinent part, as follows:

If You sustain an accidental injury that is the Direct and Sole Cause of a Covered Loss described in the Schedule of Benefits, Proof of the accidental injury and Covered Loss must be sent to Us. When We receive such Proof We will review the claim and, if We approve it, will pay the insurance in effect on the date of the injury.

Direct and Sole Cause means that the Covered Loss occurs within 12 months of the date of the accidental injury and was a direct result of the accidental injury, independent of other causes.

* * *

EXCLUSIONS

We will not pay benefits under this section for any loss caused or contributed to by:

1. physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity....

Id. at 293.

The AD & D provisions of the Summary Plan Description (SPD) stated in similar, but not identical, fashion, that "[i]f you [the participant] die as a result of, and within 12 months after, an accident, your beneficiary will receive 100 percent of your AD & D insurance coverage." Id. at 68. The SPD also stated that "losses due to ... physical or mental illness" were excluded from AD & D coverage. Id. at 69.

Cherilyn Kellogg's claim for life and AD & D benefits

On February 9, 2005, Kellogg's attorney submitted to Metropolitan Life Insurance Company (MetLife), the claims administrator, a formal claim for life and AD & D benefits under the Plan. On March 8, 2005, MetLife sent a letter to Kellogg's attorney stating that, "[i]n order for [it] to consider the claim for [AD & D] insurance benefits," it "require[d]" a "Copy of the Police Report," a "Copy of the Autopsy Report," a "Copy of the Toxicology Report," and "Newspaper clippings." Id. at 116.

On March 25, 2005, MetLife sent a letter to Stephen Morris, a deputy coroner with the Merced County Sheriff's Department, asking for "[a] written statement by the medical examiner/coroner on their letterhead stating the manner of [Brad Kellogg's] death." Id. at 113. On March 30, 2005, Morris sent a letter back to MetLife, on Sheriff's Department letterhead, stating as follows:

Brad Kellogg (DOB 07/12/1968), expired on 09/06/2004 at Mercy Medical Center, Community Campus in the city of Merced in Merced County California.

Mr. Kellogg's death is not the result of a homicide or suicide. He died as the result of traumatic injuries sustained in a solo motor vehicle accident. His death is considered to be accidental.

Id. at 109.

On May 10, 2005, MetLife approved Kellogg's claim for life insurance benefits under the Plan. On that same date, MetLife sent a letter to Kellogg's attorney addressing the issue of AD & D benefits and stating, in pertinent part:

In order for us to consider the claim for Accidental Death and Dismemberment Accidental insurance benefits, we will require the following:

• Copy of the Police Report

• Copy of the Autopsy Report

• Copy of the Toxicology Report/Toxicology Report

• Newspaper clippings (if available)

Id. at 87.

On June 9, 2005, Kellogg's counsel forwarded to MetLife "(i) the final Certificate of Death; (ii) a copy of the police report; (iii) a copy of the autopsy report; (iv) a copy of the toxicology report; and (v) the newspaper clippings that were in Mrs. Kellogg's possession." Id. at 166. Along with the documents, counsel sent a one-page letter to MetLife stating: "Now that you have the requested documentation, please consider this our formal request to pay the balance of the life insurance proceeds, representing the payment of accidental death and dismemberment proceeds, to Mrs. Kellogg." Id.

On June 22, 2005, MetLife personnel obtained information, via a web site called WebMDHealth, regarding the medications that the toxicology report found in Brad Kellogg's system at the time of his death. There is no indication in the administrative record that any medically-trained personnel were involved in this search or reviewed the search results.

On June 29, 2005, MetLife sent a letter to Kellogg's counsel stating as...

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