Appeals Court Upholds Denial of Accidental Death Benefits
Two things I always emphasize:
Accidental death coverage is not life insurance
ERISA cases are governed by different rules and require particular expertise
Wicks v. Metlife, involved ERISA accidental death benefits. Jackie Wicks underwent gastric sleeve surgery to address morbid obesity,. Though the procedure was initially successful, he experienced complications, including an anoxic brain injury following cardiac arrest. He was given various pain medications after the surgery, but he was subesquently found non-responsive and died days later. The death certificate noted an "unintentional narcotic overdose" as a contributing factor.
Under the employer AD&D plan governed by ERISA, Fonda Wicks sought benefits, asserting that the overdose was an accidental injury causing her husband’s death. MetLife, the plan administrator, denied the claim, citing that the death did not meet the plan’s requirement of being the "direct and sole cause" of loss, independent of other causes. In short, Metlife contended that the death did not solely result from an accidental injury as defined by the AD&D group plan. Instead, his death was in part the result of complications from surgery: “Mr. Wicks’[s] death stemmed from his morbid obesity; his election to undergo surgical treatment to treat his morbid obesity; and the admission of hydromorphone to treat the related pain from the surgery. Clearly, Mr. Wicks’[s] physical condition.”
Wicks filed an administrative appeal, which was denied. Fonda then sued Metlife. The federal district judge then upheld the denial of benefits:
“[B]ecause the record shows that Mr. Wicks received an appropriate dosage of Dilaudid, the [c]ourt finds that Mr. Wicks received proper medical treatment. Since Mr. Wicks received proper medical treatment, the [c]ourt finds that his death was caused by the preexisting infirmity of obesity. Because Mr. Wicks died from obesity, his death did not result from “accidental injury, independent of other causes.” As such, an “Unintentional Narcotic Overdose” is not the Direct and Sole Cause of Mr. Wicks’[s] death.”
The federal Fifth Circuit Court of Appeals affirmed the district court’s decision, concluding that:
The death was not directly and solely caused by an accident. Instead, it was influenced by morbid obesity and the surgical treatment for it.
Proper medical treatment, not negligence or overdose, was administered.
The "illness/treatment exclusion" applied, as the death stemmed from complications related to obesity treatment.
This case underscores the importance of understanding the terms and exclusions of AD&D policies. Policyholders should:
Carefully review plan documents to understand coverage limitations.
Be aware of how preexisting conditions and medical treatments may impact claims.
Seek legal guidance when navigating complex ERISA claims.
Our firm regularly evaluates and pursues recovery of denied AD&D and life insurance insurance benefits. Call attorney J. Michael Young at (800) 323-1857.