Koch v. Metro. Life Ins. Co.

• Citation: 425 F.Supp.3d 741
• Decision Date: 26 November 2019
• Docket Number: Civil Action No. 7:18-cv-00154-O
• Parties: Edythe KOCH, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Northern District of Texas

425 F.Supp.3d 741

Edythe KOCH, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

Civil Action No. 7:18-cv-00154-O

United States District Court, N.D. Texas, Wichita Falls Division.

Signed November 26, 2019

425 F.Supp.3d 743

John R. Lively, Lively & Associates LLP, Fort Worth, TX, William Douglas Knowlton, Knowlton Firm, Henrietta, TX, for Plaintiff.

Linda G. Moore, Estes Thorne & Carr PLLC, Dallas, TX, for Defendant.

MEMORANDUM OPINION AND ORDER

Reed O'Connor, UNITED STATES DISTRICT JUDGE

Before the Court are Defendant Metropolitan Life Insurance Company's ("MetLife") Motion for Summary Judgment, Brief in Support, and Appendix in Support (ECF Nos. 18–20), filed August 1, 2019; Plaintiff Edythe Koch's ("Mrs. Koch") Response, Brief in Support, and Appendix in Support (ECF Nos. 24–26), filed September 4, 2019; and MetLife's Reply (ECF No. 27), filed September 18, 2019. Having reviewed the motion, briefing, and applicable law, the Court finds that a motion for summary judgment is not the appropriate vehicle for resolution of this case. Instead, the Court must conduct a de novo review of the administrative record to determine whether MetLife correctly concluded that Mrs. Koch failed to show that an accident was the direct and sole cause of her late husband's, Barry Koch's ("Mr. Koch"), death.

Accordingly, the Court DENIES MetLife's Motion for Summary Judgment. Based on an independent review of the administrative record, the Court concludes that Mrs. Koch has not carried her burden of establishing that she is entitled to accidental death benefits based on the terms of her life insurance plan (the "Plan") and the facts included in the administrative record. Thus, the Court AFFIRMS MetLife's denial of benefits.

I. FACTUAL BACKGROUND¹

Following the unexpected death of her husband, Mrs. Koch filed a claim for accidental death benefits under her Plan. See AR 118, ECF No. 20. 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." Def.'s Br. Supp. Mot. Summ. J. 2, ECF No. 19 (citing AR 124–52). 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. See generally AR. 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," Br. Supp. Pl.'s Resp. 2, ECF No. 25 (citing AR 120, 152), MetLife reviewed

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the medical records, concluded that the death was "natural," and twice denied Mrs. Koch's claim, Def.'s Br. Supp. Mot. Summ. J. 4–6, ECF No. 19 (citing AR 193–94, 539–41).

In its letter affirming the initial denial of her claim, MetLife pointed Mrs. Koch to the Plan's exclusionary language. See AR 539–41. Under the Plan, Mrs. Koch, as the policyholder, is entitled to benefits "if [she] or [her] Dependent sustains an accidental injury that is the Direct and Sole Cause of a Covered Loss." AR 41, 540. "Direct and Sole Cause means that the Covered Loss ... was a direct result of the accidental injury, independent of other causes." Id. Additionally, the Plan specifically states that MetLife "[w]ill 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." Id. The Plan also places the burden on the policyholder to submit "Proof of the accidental injury and Covered Loss." Id.

Following MetLife's affirmance of denial, Mrs. Koch filed suit in Texas state court. See Notice of Removal 1 & Ex. A, ECF No. 1. MetLife removed the case to federal court, asserting that Mrs. Koch's state-law claims were preempted by the Employee Retirement Income Security Act of 1974 ("ERISA"). Id. at 2–3. MetLife then moved for summary judgment, arguing that the undisputed facts in the closed administrative record support its denial of accidental death benefits. See Def.'s Br. Supp. Mot. Summ. J. 14, ECF No. 19. Mrs. Koch responds that summary judgment is inappropriate, as the administrative record includes factual inconsistencies amounting to genuine issues of material fact. See Br. Supp. Pl.'s Resp. 1, ECF No. 25.

The parties contest the appropriate vehicle for resolving the case, the standard of review, and the scope of the administrative record. See generally Def.'s Br. Supp. Mot. Summ. J., ECF No. 19; Br. Supp. Pl.'s Resp., ECF No. 25. Ultimately, though, the parties' dispute boils down to a single issue: whether the evidence Mrs. Koch submitted for MetLife's review establishes that an "accidental injury" was the "[d]irect and [s]ole [c]ause" of her husband's death.

II. LEGAL STANDARD

A. Summary Judgment

The Court may grant summary judgment where the pleadings and evidence show "that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." FED. R. CIV. P. 56(a). When reviewing the evidence on a motion for summary judgment, courts must resolve all reasonable doubts and draw all reasonable inferences in the light most favorable to the non-movant. See Walker v. Sears, Roebuck & Co. , 853 F.2d 355, 358 (5th Cir. 1988). The court cannot make a credibility determination in light of conflicting evidence or competing inferences. Anderson v. Liberty Lobby, Inc. , 477 U.S. 242, 255, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). Rather, if there appears to be some support for disputed allegations, such that "reasonable minds could differ as to the import of the evidence," the court must deny the motion. Id. at 250, 106 S.Ct. 2505.

B. ERISA

Under ERISA, an insurance plan "participant or beneficiary" may file suit "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). Limiting relief to that which "will enforce ‘the terms of the plan ’ or the statute, § 1132(a)(3) (emphasis added)

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... reflects ERISA's principal function: to protect contractually defined benefits." U.S. Airways, Inc. v. McCutchen , 569 U.S. 88, 100, 133 S.Ct. 1537, 185 L.Ed.2d 654 (2013) (internal citations omitted).

In Texas, district courts review plan administrators' legal and factual determinations de novo. See Ariana M. v. Humana Health Plan of Tex., Inc. , 884 F.3d 246, 250, 256 (5th Cir. 2018). Unlike under the abuse of discretion standard, the administrator's decision to deny benefits "is not afforded deference or a presumption of correctness" when reviewed de novo. Pike v. Hartford Life & Accident Ins. Co. , 368 F. Supp. 3d 1018, 1030 (E.D. Tex. 2019). Rather, the court must "independently weigh the facts and opinions in the administrative record to determine whether the claimant has met his burden of showing that he is disabled within the meaning of the policy." Id.

"A claimant under section 1132(a)(1)(B) has the initial burden of demonstrating entitlement to benefits under an ERISA plan...." Perdue v. Burger King Corp. , 7 F.3d 1251, 1254 n.9 (5th Cir. 1993). Thus, the claimant must supply the evidence demonstrating that she is entitled to benefits by a preponderance of the evidence. See Pike , 368 F. Supp. 3d at 1031. Moreover, the administrator "is not under a duty to ‘reasonably investigate’ a claim." Gooden v. Provident Life & Accident Ins. Co. , 250 F.3d 329, 333 (5th Cir. 2001) (citing Vega v. Nat'l Life Ins. Servs., Inc. , 188 F.3d 287, 298 (5th Cir. 1999) (en banc), overruled on other grounds by Metro. Life Ins. Co. v. Glenn , 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008) ). Typically, "[o]nce the record is finalized, a district court must remain within its bounds in conducting a review of the administrator's findings, even in the face of disputed facts." Ariana M. , 884 F.3d at 256 (citing Vega , 188 F.3d at 299 ). Departure from this rule is only appropriate "in very limited circumstances." Id.

III. ANALYSIS

Based on the terms of the Plan and the evidence in the administrative record, the Court must resolve whether Mrs. Koch has proven by a preponderance of the evidence that an "accidental injury" was the "[d]irect and [s]ole [c]ause" of her husband's death. AR 41. However, before analyzing the merits of Mrs. Koch's claim, the Court must determine the appropriate vehicle for their resolution, the proper standard of review, and the scope of the administrative record.

A. Summary Judgment

MetLife contends that "[t]he undisputed evidence supports MetLife's claim determination that accidental death benefits were not payable under the terms of the Plan because [Mr. Koch's] death was ‘caused or contributed to by ... physical or mental illness or infirmity’ " and urges the Court to uphold its...