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Smith v. Metropolitan Life Insurance Co.

United States District Court, E.D. Michigan, Southern Division

May 19, 2017

ROBERT SMITH, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

          ORDER GRANTING DEFENDANT'S MOTION TO AFFIRM THE ADMINISTRATOR'S DECISION [DKT. NO. 9], DENYING PLAINTIFF'S MOTION FOR REVERSAL OF ADMINISTRATIVE DENIAL OF CLAIM FOR BENEFITS [DKT. NO. 10] AND DISMISSING PLAINTIFF'S CAUSE OF ACTION

          Denise Page Hood Chief Judge.

         I. INTRODUCTION

         Plaintiff Robert Smith is an intended beneficiary of his late wife Debra T. Smith (“Mrs. Smith”) pursuant to the terms and provisions of the Dependant Life Insurance (“DLI”) and the Voluntary Accidental Death and Dismemberment (“AD&D”) Insurance Plan Policy No. 73903 purchased by his employer FCA L.L.C. (“FCA”). Following the tragic death of Mrs. Smith, Plaintiff made a timely claim for disbursement of DLI and AD&D benefits with the Policy administrator, Defendant Metropolitan Life Insurance Company (hereinafter “Defendant”). Defendant paid Plaintiff's claim for DLI benefits, but denied his claim for AD&D benefits because of the manner of Mrs. Smith's death. Plaintiff filed a breach of contract suit in Oakland County Circuit Court. Defendant removed the case to this Court because the pertinent issues of Plaintiff's claims are governed by the Employment Retirement Income Security Act (“ERISA”).

         Defendant and Plaintiff filed cross-dispositive motions on February 16, 2017 [Dkt. Nos. 9, 10], and Defendant filed a response to Plaintiff's motion. The Court, having concluded that the decision process would not be significantly aided by oral argument, ordered that the motions be resolved on the motion and briefs submitted by the parties. E.D. Mich. L.R. 7.1(f)(2). [Dkt. No. 13] For the reasons that follow, the Court grants Defendant's motion, denies Plaintiff's motion, and dismisses Plaintiff's cause of action.

         II. BACKGROUND

         Plaintiff participated in the Voluntary Group Accident Insurance Program (“Plan”) available to FCA employees, and he insured Mrs. Smith under Dependent Life Insurance (“DLI”) and Voluntary Accidental Death and Dismemberment Insurance (“AD&D) policies. Mrs. Smith died on February 28, 2016. According to the Death Certificate, Mrs. Smith died after she “Ingested washer fluid in craving for alcoholic beverage.” [Dkt. No. 9, Ex. A] The Death Certificate includes a section for identifying the manner of death, with the following options: “Accident, Suicide, Homicide, Natural, Indeterminative or Pending.” Id. The Death Certificate reflects that the medical examiner determined that Mrs. Smith's manner of death was “Accident.” Id.

         On March 15, 2016, Plaintiff applied for DLI and AD&D benefits under the Plan because of his wife's death. The Plan defines the eligibility criteria for AD&D benefits as follows:

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
If You or a Dependent 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.
We will deem a loss to be the direct result of an accidental injury if it results from unavoidable exposure to the elements and such exposure was a direct result of an accident.

[Dkt. No. 9, Ex. B] The Plan does not define “accidental injury.”

         The Plan provides that some events preclude an award of AD&D benefits. In relevant part, the Exclusions section provides:

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 ...

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