California Court Agrees with MetLife’s Denial of Dismemberment Claim

Dowdy v. Metropolitan Life Insurance Company (MetLife) is a sad case for plaintiffs who have a pre-existing condition that contributes to their otherwise qualifying event for collecting insurance benefits. Thomas Dowdy and his wife had purchased an accidental death and dismemberment policy through Mrs. Dowdy’s employment at Bank of the West.

Plaintiff Thomas Dowdy was in a one-car accident in which he suffered numerous severe injuries. His medical report immediately following the accident described an ankle injury as a “near amputation.” Five months later, his doctors noted that, due to his diabetes, the injury had never healed. Instead, the leg became infected to the degree that surgical amputation just below the knee was required. MetLife denied his application for dismemberment benefits on the grounds that the accident was not the “sole cause” of the amputation as required by the language of the policy.

After exhausting their administrative appeals, Mr. and Mrs. Dowdy filed this ERISA lawsuit. The district court agreed with MetLife and ruled that “Plaintiffs have not demonstrated that they are entitled to coverage under their coverage polices with Defendant.”

Policy Requirement of “Sole Cause”

The policy clearly stated that in order to qualify for benefits, the dismemberment must be the “Direct and Sole Cause” of a covered loss. It defined this further, requiring the loss to occur “within 12 months of the date of the accidental injury and was a direct result of the accidental injury, independent of other causes…We will not pay benefits under this section for any loss caused or contributed by physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity.”

The court found that Mr. Dowdy’s diabetes “clearly contributed to his loss.” The court considered all plaintiffs’ claims before finally stating, “The Court concludes that Mr. Dowdy’s diabetes caused or contributed to his need for amputation.”

Plaintiffs Did Not Demonstrate a “Clear Necessity” for Consideration of Extrinsic Evidence

Although plaintiffs admitted that ERISA lawsuits are generally limited to the administrative record, they asked the court to consider extrinsic evidence on the grounds that MetLife had not been helpful to them in submitting their claim, and if MetLife had informed them of some medical reports that were needed, they would have submitted them. They claimed that MetLife did not comply with its “fiduciary duty to assist its beneficiaries.”

The court disagreed, noting that the burden is on the plaintiff to determine what is needed and to provide the necessary proof to support the claim. In denying the request to consider the extrinsic evidence, the court noted that, even if it did consider it, which it did not, the extra medical record did not “refute the basic conclusion” that the amputation was due to complications of diabetes and the accident was not the “sole cause” of the dismemberment as required by the policy language.

The court’s final statement: “Plaintiffs have not demonstrated a clear necessity for the Court to consider evidence beyond the administrative record. Plaintiffs have also not met their burden of demonstrating entitlement to benefits under their accidental death and dismemberment insurance plan.”

This case was not handled by our office, but we thought it may be helpful to those pursuing claims under their accidental dismemberment clause of an insurance policy. If you have questions about your own claim for benefits, contact one of our attorneys for a free case evaluation.

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