Jones v. Metro Life ( 2004 )

RECOMMENDED FOR FULL-TEXT PUBLICATION
Pursuant to Sixth Circuit Rule 206 2 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
ELECTRONIC CITATION: 2004 FED App. 0330P (6th Cir.)
File Name: 04a0330p.06 _________________
COUNSEL
UNITED STATES COURT OF APPEALS
ARGUED: Barbara H. Goldman, SHELDON L. MILLER &
FOR THE SIXTH CIRCUIT ASSOC., Southfield, Michigan, for Appellant. Mark D.
_________________ Filak, HARDY, LEWIS & PAGE, Birmingham, Michigan,
for Appellees. ON BRIEF: Barbara H. Goldman,
DOLORES K. JONES, X SHELDON L. MILLER & ASSOC., Southfield, Michigan,
Plaintiff-Appellant, - for Appellant. Kay R. Butler, David M. Davis, HARDY,
- LEWIS & PAGE, Birmingham, Michigan, for Appellees.
- No. 03-1375
v. - _________________
>
, OPINION
METROPOLITAN LIFE - _________________
INSURANCE COMPANY , -
GENERAL MOTORS , and - KAREN NELSON MOORE, Circuit Judge. This action
GENERAL MOTORS LIFE AND - arose from Defendant-Appellee, Metropolitan Life Insurance
DISABILITY BENEFITS - Company (“MetLife”)’s, denial of Plaintiff-Appellant,
- Dolores K. Jones (“Jones”)’s, claim for benefits under a
PROGRAM,
- Personal Accident Insurance (“PAI”) policy in an employee
Defendants-Appellees. - benefits plan (“Plan”) provided by General Motors (“GM”)
N and governed by the Employee Retirement Income Security
Appeal from the United States District Court Act of 1974 (“ERISA”). Jones appeals the district court’s
for the Eastern District of Michigan at Detroit. judgment granting MetLife’s motion for judgment on the
No. 02-70704—George C. Steeh, District Judge. administrative record and denying Jones’s dispositive motion.
Jones first asserts on appeal that the district court should have
Argued: August 13, 2004 evaluated under a modified-arbitrary-and-capricious standard
the denial of PAI benefits to Jones because MetLife was
Decided and Filed: September 29, 2004 operating under a conflict of interest, as it was both the
insurer and an administrator of the Plan. Jones next asserts on
Before: MOORE and COLE, Circuit Judges; MARBLEY, appeal that the district court erred by accepting MetLife’s
District Judge.* definition of the term “accident,” which requires a claimant to
demonstrate “unusual activity” or an “external force or
event.” Jones argues that MetLife’s definition is arbitrary and
capricious, and that the district court should have applied the
*
federal-common-law definition of accident promulgated by
The Honorable Algenon L. Marbley, United States District Judge for the First Circuit in Wickman v. Northwestern National
the Southern District of Ohio, sitting by designation.
1
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 3 4 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
Insurance Co., 908 F.2d 1077, 1088 (1st Cir.), cert. denied, interpret the terms of the Program and to
498 U.S. 1013 (1990), which merely requires the claimant to determine eligibility for and entitlement to
demonstrate that the injury was neither subjectively expected Program benefits in accordance with the terms
nor objectively foreseeable. of the Program. Any interpretation or
determination made by the Program
For the following reasons, we REVERSE the district Administrator or the Carrier, pursuant to such
court’s judgment granting MetLife’s motion for judgment on discretionary authority, shall be given full force
the administrative record and REMAND this case to the and effect, unless it can be shown that the
district court with instructions to remand this claim to interpretation or determination was arbitrary
MetLife for reconsideration of Jones’s medical evidence in and capricious. The determination of the
light of this opinion. Corporation or, in the event of an appeal, of the
Carrier, shall be final and binding on the
I. BACKGROUND Corporation, the insurance company and the
Employee or the Employee’s designated
A. Relevant Plan Provisions beneficiary.
This action arose from MetLife’s denial of Jones’s claim Joint Appendix (“J.A.”) at 268 (GM Plan). The parties also
for PAI benefits under a Plan provided by GM and insured by agree that the above-quoted provision requires that courts
MetLife. The parties agree as to which provisions of the Plan give some deference to MetLife’s interpretation of the Plan
are relevant to this appeal. First, the parties agree that, and evaluation of claims under the plan, and therefore, that
through the following provision, GM has expressly reserved this court should evaluate MetLife’s denial of benefits under
and delegated to MetLife discretionary authority to interpret some permutation of the arbitrary-and-capricious standard.
the Plan and to evaluate claims under the Plan: The parties disagree, however, over whether the denial of
benefits should be evaluated under a less deferential,
(b) Administration and Amendment modified-arbitrary-and-capricious standard because MetLife
(1) The Corporation, as the Program Administrator, was operating under a conflict of interest, as it was both the
shall be responsible for the administration of insurer and an administrator of the Plan.
the Program. The Corporation reserves the Second, the parties agree that Jones’s claim for PAI
right to amend, modify, suspend or terminate benefits must be determined under the following provision:
the Program in whole or in part, at any time by
action of its Board of Directors or other (i) Payment of Benefits
committee or individual expressly authorized
by the Board to take such action. . . . The If, while insured for Personal Accident Insurance, an
Program Administrator expressly reserves the Employee, Spouse or Dependent Child sustains
right to construe, interpret and apply the terms accidental bodily injuries, and within one year
of this Program. In carrying out its thereafter shall have suffered loss of life or any other
responsibilities under the Program, the Carrier loss set forth in subsection (e), as a direct result of
also shall have discretionary authority to such bodily injuries independently of all other
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 5 6 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
causes, the Carrier shall pay the benefit specified for requesting PAI benefits. On that form, Jones described the
all such Losses. . . . circumstances leading to her knee injury as follows:
“BENDING DOWN AND SQUATTING TO GIVE FIRST
... AID TO EMPLOYEE – FELT SHARP PAIN IN MY RIGHT
KNEE IMMEDIATELY AFTER I STOOD FROM
Only one amount, the largest to which the SQUATTING POSITION.” J.A. at 60 (claim form). Also on
beneficiary is entitled, will be paid for all losses that form, Jones indicated that she became disabled on June 1,
suffered by one covered individual resulting from 1999, and was certified unable to work on May 31, 2000.1
one accident.
On December 5, 2000, MetLife wrote to Jones informing
J.A. at 333 (GM Plan). The Summary Plan Description her that her claim for PAI benefits had been denied because
provides: Jones’s description of her knee injury “does not constitute an
accident for purposes of the payment of Total and Permanent
If you become totally and permanently disabled as a Disability Benefits under [Jones’s] Personal Accident
result of an accidental injury while you are an active Insurance” and because Jones’s “physician has not indicated
employee you will be paid the full benefit amount of any that [Jones is] totally and permanently disabled due to [her]
personal accident insurance (PAI) you elected in monthly injury.” J.A. at 65 (MetLife letter 12/5/2000). In its
installments of 2% of that amount less any amount paid December 5, 2000 letter, MetLife stated that it would “gladly
for losses previously sustained, provided you submit consider any additional information you wish to submit
evidence satisfactory to the insurance company. “Total supporting your claim. . . . The additional information will be
and permanent disability” under PAI means the total and re-evaluated and Metropolitan Life will advise you of its
permanent inability, as caused by an accidental injury, to findings.” J.A. at 66 (MetLife letter 12/5/2000). On
engage in regular employment or occupation for December 19 and 26, 2000, Jones sent to MetLife additional
remuneration or profit, as based on medical evidence documentation supporting her claim, including a doctor’s
satisfactory to the insurance company. receipts that indicate her diagnosis was “tear knee medial
meniscus,” her Social Security award letter for disability
J.A. at 88 (GM Summ. Plan Description). The parties agree insurance, a claim form for PAI benefits that her treating
that Jones’s claim for PAI benefits turns upon the definition physician, Dr. Salamon, had completed in more detail, and a
of the term “accident,” and that the term “accident” is not statement from Jones’s physician. J.A. at 87 (Jones letter
defined in the Plan or the Summary Plan Description. The 12/26/2000).
parties disagree, however, over whether the definition
proffered by MetLife in the course of denying Jones’s claim On February 9, 2001, MetLife wrote to Jones again
is arbitrary and capricious. informing her that her claim for PAI benefits had been denied
because “‘bending down and squatting’, is not sudden,
B. Factual Background unexpected and unforeseen. Therefore, it does not constitute
Jones worked as an industrial nurse for GM. On
February 22, 1999, Jones injured her knee at work. On
1
September 1, 2000, Jones submitted to MetLife a claim form In its letters, M etLife indicates that both of these events oc curred in
1999.
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 7 8 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
an accident for purposes of the payment of Total and policy and inform her of MetLife’s definitions of the terms
Permanent Disability Benefits under you[r] Personal Accident “accident” and “total and permanent disability” in order to
Insurance.” J.A. at 63 (MetLife letter 2/9/2001). In its enable Jones to provide MetLife with appropriate
February 9, 2001 letter, MetLife informed Jones that she documentation of her injury.
could appeal this decision and could include in that appeal
“any additional information that [she] wish[ed] to be On May 7, 2001, MetLife wrote to Jones denying her
considered.” J.A. at 64 (MetLife letter 2/9/2001). appeal. In its May 7, 2001 letter, MetLife stated:
On April 9, 2001, Jones wrote to MetLife appealing the The [PAI] plan itself does not define the word “accident”
December 5, 2000 and February 9, 2001 denials of her claim or “accidental,” but applicable federal law does. Under
for PAI benefits. In her April 9, 2001 letter, Jones explained applicable federal law, “accident” means an unforeseen
that “while in the course of my employment, and in an undesigned sudden or unexpected event of an unfortunate
emergency first aid situation, that while I bent down to a character. However, injuries resulting from natural and
squatting position in order to administer first aid that I hypo ordinary activities are not “accidental” when there are no
extended my knee causing a rip and tear to the medial external forces or events to trigger the injuries. For
meniscus”2 and stated that Taber’s Cyclopedic Medical example, a knee injury from bending and/or squatting
Dictionary defines “accident injury” as “‘[o]ccuring suddenly, does not constitute an accident.
un ex pe ct ed ly, inadvertently; under unforeseen
circumstances.’” J.A. at 67 (Jones letter 4/9/2001) (emphasis In your case, there was no outside occurrence that caused
added). Jones further stated in her April 9, 2001 letter that your injury. In the course of your employment as a
she felt “that an unexpected tear in the medial meniscus registered nurse, you bent down and squatted to give first
received during the course of performing [her] job clearly aid to an employee. Consequently, your knee injury was
constitutes an accident. . . . [and that] MIOSHA3 deems [her] natural and not accidental. (While MIOSHA may have
injury an accident.” J.A. at 67-68. In her April 9, 2001 letter, deemed your injury to be an accident, a determination by
Jones also requested that MetLife send her a copy of the PAI MIOSHA is not binding on the Plan.)
...
2
Based upon the administrative reco rd, it is not clear whether Jones
. . . Since we have determined that your injury was not
erroneously used the modifier “hypo” instead of “hyper” when describing accidental, there was no need to closely examine your
her knee injury. The medical dictionaries that we consulted did no t list a medical evidence.
definition for the term “hyp o-extension.” Dorland ’s defines
“hyperextension” as “extreme or excessive extension of a limb or pa rt,” J.A. at 69-70 (MetLife letter 5/7/2001).
defines “hypo” as “a p refix signifying bene ath, und er, below normal, or
deficient,” and does not include a definition for the term “hypo- C. Procedural Background
extension.” Dorland’s Illustrated Medical Dictionary 881, 892 (30th ed.
2003); see also Ta ber’s Cyclopedic Medical Dictionary (19th ed. 2001).
In any event, it is not for us to determine in the first instance whether On February 22, 2002, Jones filed a complaint in the
Jones erro neously described her injury. district court seeking judicial review of MetLife’s denial of
her claim for PAI benefits. The parties each filed motions for
3
Michigan Occup ational Safety and Health Administration. judgment. The district court granted MetLife’s motion for
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 9 10 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
judgment on the administrative record and denied Jones’s capricious standard applies and failed to raise in the district
dispositive motion. The district court had jurisdiction court MetLife’s alleged conflict of interest.
pursuant to 29 U.S.C. § 1132(a)(1)(B) and (e), as Jones
sought to recover benefits allegedly due under the terms of an We conclude that Jones failed to preserve her argument that
ERISA plan. This court has jurisdiction pursuant to the district court should have reviewed under a modified-
28 U.S.C. § 1291, as Jones filed a timely notice of appeal. arbitrary-and-capricious standard MetLife’s denial her claim
for PAI benefits.4 Jones conceded below that the denial of
II. ANALYSIS her claim for PAI benefits should be evaluated under the
arbitrary-and-capricious standard and did not assert below
A. Standard of Review that this standard should be modified due to MetLife’s alleged
conflict of interest. In her dispositive motion below, Jones
The parties agree that when there is no evidence of a stated, “[Jones] concedes that the case at bar should be
conflict of interest, both the district court and this court reviewed under the arbitrary and capricious standard. . . .
review de novo an administrator’s denial of benefits pursuant When it is possible to offer a reasoned explanation, based on
to an ERISA plan, unless the plan clearly grants to the the evidence, for a particular outcome, that outcome is not
administrator discretion to construe the terms of the plan or to arbitrary and capricious. . . . In other words, if the decision is
make benefit determinations. Wilkins v. Baptist Healthcare ‘rational in light of the plan’s provisions’ it should be
Sys., Inc., 150 F.3d 609, 613 (6th Cir. 1998) (citing Firestone upheld.” J.A. at 567 (Pl’s Dispositive Mot.) (internal
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). The citations omitted). Additionally, in her response to MetLife’s
parties also agree that if a plan expressly grants to the motion for judgment on the administrative record, Jones
administrator such discretion, and there is no evidence of a stated, “[Jones] admits that under the GM Plan, discretionary
conflict of interest, both the district court and this court must authority has been retained by [MetLife] and that the standard
review the administrator’s denial of benefits under the highly of review is pursuant to an arbitrary and capricious standard.”
deferential arbitrary-and-capricious standard of review. Moos J.A. at 583 (Pl’s Resp.). Therefore, we will evaluate under
v. Square D Co., 72 F.3d 39, 41 (6th Cir. 1995). Moreover, the deferential arbitrary-and-capricious standard of review
the parties agree that when reviewing an administrator’s MetLife’s denial of Jones’s claim for PAI benefits.
denial of benefits pursuant to an ERISA plan, both the district
court and this court may typically review only evidence
contained in the administrative record. Wilkins, 150 F.3d at
619.
4
Typically, parties may not determine by agreement our standard of
Jones first asserts on appeal that the district court erred by review. K & T Enters., Inc. v. Zurich Ins. Co., 97 F.3d 171, 175 (6th Cir.
reviewing under the arbitrary-and-capricious standard the 1996). It this case, however, the level of deference accord ed to MetLife’s
denial of her claim for PAI benefits, arguing that MetLife had denial of benefit turns upon a factual circumstance, i.e., whether or not
a conflict of interest due to its status as both the insurer and MetLife was operating under a conflict of interest, and parties may
concede the existence of facts. In this case , Jones’s concession in the
an administrator of the Plan. In response, MetLife argues that district court that MetLife’s denial of her claim for benefits should be
Jones has not preserved her argument that the district court reviewed under the arbitrary-and-capricious standa rd and Jo nes’s failure
should have modified the arbitrary-and-capricious standard, to assert that MetLife was operating under a conflict of interest are
as Jones conceded in the district court that the arbitrary-and- tantamount to a concession of fact, and not to an agreement to waive the
appropriate standard of review.
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 11 12 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
It is true that, “[r]eview under [the arbitrary and capricious] Employees’ Stock Ownership & Profit Sharing Plan v.
standard is extremely deferential and has been described as Robinson, 164 F.3d 981, 986 (6th Cir. 1999), cert. denied,
the least demanding form of judicial review.” McDonald v. 528 U.S. 1114 (2000); Moos, 72 F.3d at 42-43. Discretion to
Western-Southern Life Ins. Co., 347 F.3d 161, 172 (6th Cir. interpret a plan, however, does not include the authority to
2003). “Under this deferential ‘arbitrary and capricious’ add eligibility requirements to the plan. See Univ. Hosps. of
standard, we will uphold a benefit determination if it is Cleveland, 202 F.3d at 849-50.5 We conclude that MetLife
‘rational in light of the plan’s provisions.’” Univ. Hosps. of acted arbitrarily and capriciously when it interpreted the term
Cleveland v. Emerson Elec. Co., 202 F.3d 839, 846 (6th Cir. “accident” in a manner that adds requirements not found in
2000) (quoting Yeager v. Reliance Standard Life Ins. Co., the Plan documents or supported by federal common law.
88 F.3d 376, 381 (6th Cir. 1996)). The arbitrary-and-
capricious standard, however, does not require us merely to The Plan documents do not define the term “accident.”
rubber stamp the administrator’s decision. McDonald, 347 Specifically, the Plan documents do not require that an
F.3d at 172. Under the arbitrary-and-capricious standard, insured be engaged in “unusual activity” or meet with an
both the district court and this court must exercise review “external force or event” in order for her injury to be
powers. Id. considered an accident. MetLife could have expressly
included such a requirement. Indeed, many of the insurance
B. Definition of Accident policies discussed in the cases cited by the parties did contain
such a requirement. Because the policy at issue in this case
Jones next argues on appeal that the district court erred by did not include an “unusual activity” or “external force or
concluding that MetLife’s definition of the term “accident” is event” requirement, MetLife attempts to rely upon federal
not arbitrary or capricious. Jones asserts that the district court common law to supply this requirement.
should have applied the federal-common-law definition of
accident promulgated by the First Circuit in Wickman, which As evidenced by the cases cited in the parties’ briefs, the
merely requires the claimant to demonstrate that the injury definition of the term “accident” has been heavily litigated
was neither subjectively expected nor objectively foreseeable. throughout history. The cases cited by Jones are of two
In response, MetLife argues that the district court properly varieties — (1) those in which the insured had engaged in
held that MetLife’s definition of the term “accident” is not risky behavior and the question being reviewed was whether
arbitrary or capricious. MetLife asserts that Wickman is the resulting injury was accidental;6 and (2) those in which an
distinguishable, in that there the insured’s “injuries resulted
from an occurrence outside the usual course of events.”
Appellee’s Br. at 32. MetLife argues that several federal 5
W e recognize that in Un iversity H ospitals, we gave less deference
cases decided under the arbitrary-and-capricious standard to the administrato r’s interpretation because the administrator was
have upheld administrators’ interpretation of “accident” as operating under a conflict of interest. Univ. Hosps. of Cleveland v.
requiring “unusual activity” or an “external force or event.” Emerson Elec. Co., 202 F.3d 839 , 846 -47 (6 th Cir. 2000 ). Nevertheless,
we conclude that under even the most deferential review, adding
At the outset, we note that because the Plan expressly eligibility requirements to a plan is arbitrary and cap ricious.
granted to MetLife authority to interpret the Plan, we must 6
give deference to MetLife’s interpretation of ambiguous and For examples of this variety of case, see Cozzie v. M etro. Life Ins.
general terms of the Plan. See Admin. Comm. of the Sea Ray Co., 140 F.3d 1104, 1106, 110 9-10 (7th C ir. 199 8) (ho lding that insured ’s
injury was foreseeable, and thus not acciden tal, within the m eaning of a
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 13 14 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
event had triggered an injury and the question being reviewed
was whether a preexisting condition prevented the injury from
policy that covered “injuries caused solely by an accident” and was being considered accidental.7 In the cases cited by MetLife,
governed by ERISA, when insured died in car wreck that occurred when
insured was driving while intoxicated); Wickman v. Northwestern Nat’l
Ins. Co., 908 F.2d 107 7, 10 88-8 9 (1st Cir.), cert. denied, 498 U.S. 1013
(1990) (holding that insured’s injury was foreseeable, and thus not unintentionally ingested a fatal do se of morphine); Santaella v. Metro.
accid ental, within the mea ning of a policy that defined accident as “an Life Ins. Co., 123 F.3d 456, 463-65 (7th Cir. 1997) (applying de novo
unexpected, external, violent and sudden event” and was governed by review beca use the p lan did not give to administrato r discre tion to
ERISA, when insured died after climbing outside of guardrail on an interpret the policy and holding that insured’s death from a prescription
overpass and jumping or falling to the ground forty to fifty feet below); overdose was caused by an accident where the evidence indicated that the
Nelson v. Sun Life Assurance Co. of Canada, 962 F. Supp. 1010, 1012-13 insured unintentionally ingested a fatal dose of codeine).
(W.D. Mich. 1997) (holding that insured’s injury was foreseeable, and 7
thus not caused solely by an accident independent of all other causes, For examples of this variety of case, see Metro. Cas. Ins. Co. of N.Y.
within the meaning of a po licy governed by ERISA, when insured died in v. Fairchild, 220 S.W.2d 803, 804-06 (Ark. 1949) (hold ing that under
car wreck that occurred when insured was driving while intoxicated); state law, insured’s fatal heart attack brought about by strain from thawing
Walker v. Metro. Life Ins. Co., 24 F . Supp. 2d 77 5, 780-81 (E.D . Mich. ice valve on roof was caused by an accident even though act of leaning
1997) (same ); Miller v. Auto-Alliance Int’l, Inc., 953 F. Supp. 172, 175-77 over roof to thaw the valve was voluntary, and also holding that the injury
(E.D. Mich. 19 97) (same ); Cates v. Metro. Life Ins. Co., 14 F. Supp. 2d was caused by “external, violent and accidental means,” independent of
1024, 1027 (E .D. Tenn. 199 6) (same); Fowler v. Metro. Life Ins. Co., 938 all other causes even though insured may ha ve had a heart cond ition, so
F. Supp. 476, 48 0 (W .D. Tenn. 199 6) (same); Holsinger v. New England long as thawing the valve was the proximate cause of the injury);
Mu t. Life Ins. Co., 756 F. Supp. 1279 (E.D. Mich. 1991) (holding that Carrothers v. Knigh ts of Columbus, 295 N.E.2d 307, 309-310 (Ill. App.
insured ’s injury was foreseeable, and thus not caused solely by an Ct. 1973) (holding that under Illinois law, insured’s fatal heart attack
accident independent of all other causes, within meaning of policy brought about by assault was caused by an accident, not by intentional
governed by ERISA, when insured died from non-therapeutic, intentional injury inflicted b y another, where assailant did not intend to inflict fatal
ingestion of codeine). injury, and also holding that the injury was caused by an accident
The parties mentioned, but did not cite, cases deciding whether independent of all other causes, even though insured had hardened
claima nts could recover accidental death benefits when the insured died arteries, so long as the assault was the proximate cause of the injury); Am.
during autoerotic asphyxiation. The Seco nd, Ninth, and Fifth Circuits, States Ins. Co. v. Morrow, 409 N.E.2d 1140, 1141-42 (Ind. Ct. App.
applying Wickm an, have allowed such claimants to recover, but in each 1980) (holding that under Indiana law, insured’s fatal heart attack brought
instance, the court reviewed the denial of benefits de novo beca use the about by smoke inhalation was caused by “external, violent and accidental
plan did no t give to the adm inistrator discretion to interpret the policy or means,” indep endent of all other causes, even though insured may have
to make bene fit determ inations. See Critchlow v. First UNUM Life Ins. had a heart condition, because jury found that smoke inhalation was the
Co. of Am., —F.3d—, 2004 WL 1773550, at *12-13 (2d Cir. Aug. 9, proximate cause of the injury); Rankin v. United Commerc ial Travelers
2004) (holding that insured’s death during autoerotic asphyxiation was of Am., 392 P.2d 894, 901-02 (Kan. 1964) (holding that under Kansas
caused solely by an accident, not by suicide or intentionally self-inflicted law, insured’s fatal heart attack b rought abo ut by heat and exertion in
injury, within the m eaning of po licy governed by ERISA); Padfield v. fighting pasture fire was caused by “external, violent and accidental
AIG Life Ins. Co., 290 F.3d 1121, 1125, 1127-30 (9th C ir.), cert. denied, means . . . indep endent of all o ther causes,” where there was no evidence
537 U.S. 10 67 (200 2) (same); Todd v. AIG Life Ins. Co., 47 F.3d 1448, that insured previously suffered from physical impairment); Brown v.
1451-53, 1456 (5th Cir. 1995) (same). Similar reasoning was used by the Metro. Life Ins. Co., 327 S.W.2d 252, 255-56 (Mo. 1959) (holding under
Eighth and Seventh Circuits in cases deciding whether claimants could Missouri law, insure d’s fatal co ronary occlusion b rought abo ut by assa ult
recover accidental death benefits when the insured died from a drug by another person was caused by “external, violent and accidental
overdose. See, e.g., She eha n v. G uardian Life Ins. Co., 372 F.3d 962 (8th means,” indep endent of all other causes, even though insured had a heart
Cir. 2004) (giving less deference to the administrator due to a conflict of condition, because jury found that the assault was the proximate cause of
interest and holding that insured’s death from acute morphine intoxication the injury); Hu ghe s v. Pro viden t Mu t. Life Ins. C o. of P hilad elphia, 258
was caused by an accident, where the evidence indicated that the insured S.W .2d 290 , 291-94 (Mo. Ct. App. 1953) (holding under Missouri law,
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 15 16 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
the proximate cause of the injury was not obvious and the MetLife, the insured died from a heart attack. Many of these
requirement that the insured have been engaged in unusual cases hold that there is a presumption that a heart attack is
activity or that there have been some external force is caused by natural causes, which may be rebutted by evidence
intended to ensure that the injury resulted from an accident, of unusual activity, unforeseen trauma, or external force.
rather than from natural causes.8 In most of the cases cited by MetLife cites no cases, nor could we find any, suggesting that
there is a presumption that a knee injury or similar ailment is
caused by natural causes. When there is no presumption that
an injury resulted from natural causes, federal common law
that insured ’s brain hemorrhage brought about by sneezing attack caused does not require proof aimed at rebutting such a presumption.
by insured inhaling whiskers from his razor was caused “ind ependently
of all other causes . . . through external, violent and accide ntal means,”
even though insured may ha ve had weakened bloo d vessel, bec ause d eath
Contrary to MetLife’s assertion, federal common law —
followed closely after sneezing attack and weakened blood vessel was not from pre-Erie diversity cases to present day ERISA cases —
a proximate cause of injury); N.Y. L ife Ins. C o. v. W ise, 251 P.2d 1058,
1061-62 (Okla. 1953) (holding that under state law, rup tured veins in
esophagus brought about by insured pushing a car up a hill were caused rebut presumptio n that insured suffered from heart d isease necessary to
by “external, violent and accidental means” because the ruptured veins prove that the accidental bodily injury was “independent[] of all other
were an unforeseeable consequence, and also holding that the injury was causes”); Riesterer v. Crown Life Ins. Co., 653 F.2d 268 , 268 -70 (6 th Cir.
independent of other causes, even though insured had cirrhosis of the liver 1981) (holding that under Michigan and Oregon law, a fatal heart attack
which may have caused varicose veins in his esophagus, because the jury suffered by insured fireman carrying hose inside burning building was not
found that pushing the car was the proximate cause of the injury); Home “accidental bod ily injury . . . independent of all other causes,” where
Ben efit Ass’n of Paris v. Sm ith, 16 S.W.2d 357, 359 (Tex. Civ. App. insured was engaged in normal work activities and there was no external
1929); (holding that under state law, ruptured blood vessel brought about force); Sangster v. Metro. Life Ins. Co., 54 F. Supp. 2d 708, 712 (E.D.
by hand cranking a Ford was caused by an accident because it was Mich. 1999) (holding that fatal heart attack suffered by insured
unforeseeable, even though the cranking was intentional, and also holding imme diately following car wreck was not caused solely by an accident
that death was an accident, even though insured may have had hardened within the meaning o f a plan govern ed by E RISA because insured’s heart
arteries, because the jury found that hand cranking was the proxim ate con dition was an interdependent cause of insured’s death); Kolowski v.
cause of the injury); Stoffel v. Am. Family Life Ins. Co., 164 N.W.2d 484, Metro. Life Ins. Co., 35 F. Supp. 2d 1059, 1062-63 (N.D. Ill. 1998)
487-90 (W is. 196 9) (ho lding that under W isconsin law, rup tured aorta (holding that under Illinois law, fatal hea rt attack suffered b y police
brought about by insured lifting a tractor wheel was caused by an accident officer six days after a major drug bust during which officer moved three
because it was unforeseeab le, even though lifting was intentional, and also hundred pounds o f cannabis was brought about by natural causes, and not
holding that death was independent of other causes, even though insured by an accident independent of all other causes, because the drug bust was
had cystic medionecrosis, because the jury found that insured would have part of the officer’s normal job functions and there was no unforseen
suffered considerable injury absent his pre-existing condition). trauma or external force); Desroches v. Monumental Life Ins. Co., No. C
8
97-4593 VRW , 1998 WL 4 70473, at *3-4 (N.D. Cal. 1998) (holding that
For exam ples of this variety of case, see Mers v. Ma rriott Int’l under California law, fatal heart attack suffered by insured after choking
Group Accidental Death & Dismemberment Plan, 144 F.3d 1014, 1021, on her vomit was not caused by an accident independent of all other
1024 (7th Cir.), cert. denied, 525 U.S. 947 (1998) (holding that insured’s causes because it was not the result of an unforeseen e vent, but rather a
fatal heart attack was not caused solely by an accident within the meaning foreseeable consequence of insured’s pre-existing illness); Howard v.
of a policy governed by ERISA because there was evidence that insured Nat’l Educ. Ass’n of N.Y., 984 F. Supp. 103, 108-09 (N.D.N.Y. 1997)
suffered from heart disease); Winchester v. Prudential Life Ins. Co. of (holding that fatal heart attack suffered by insured who was under a great
Am., 975 F.2d 147 9, 14 85-8 8 (10th Cir. 199 2) (ap plying U tah law to deal of stress from work was not an accidental injury within the meaning
interpret a plan governed by ERISA and holding that a fatal heart attack of a plan governed by ERISA because there was no unforseen trauma or
suffered by insured was not a “bodily injury” where there was no external external force); Haley v. Am . Int’l Life Assurance Co. of N.Y., 789 F.
violence, and also holding that the claim ant had not pu t forth evid ence to Supp. 260 , 263-64 (N.D . Ill. 1992) (same).
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 17 18 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
focuses upon the expectations and intentions of the insured. reject the accidental means versus accidental results
Some of these cases adhere to the accidental means versus distinction and hold that an injury is accidental if it is neither
accidental results distinction, but hold that an injury caused subjectively expected nor objectively foreseeable. Critchlow
by an unintended and unexpected mishap during the course of v. First UNUM Life Ins. Co. of Am., —F.3d—, 2004 WL
an intentional activity is caused by accident.9 Other cases 1773550, at *12-13 (2d Cir. Aug. 9, 2004); Padfield v. AIG
Life Ins. Co., 290 F.3d 1121, 1125, 1127-30 (9th Cir.), cert.
denied, 537 U.S. 1067 (2002); Cozzie v. Metro. Life Ins. Co.,
9
Com pare United States Mut. Acc. Ass’n v. Barry, 131 U.S. 100, 101, 140 F.3d 1104, 1109-110 (7th Cir. 1998); Santaella v. Metro.
121-22 (1889) (holding that insured’s death brought about by injury Life Ins. Co., 123 F.3d 456, 463-65 (7th Cir. 1997); Todd v.
caused by mishap during intentional jump from platform to ground below AIG Life Ins. Co., 47 F.3d 1448, 1456 (5th Cir. 1995);
was accidental within the meaning of a policy that covered death from Wickman, 908 F.2d at 1088-89. Jones presented to the
bod ily injuries caused by “external, violent, and accidental means”); administrator evidence that may pass either test. Jones
Aetna Life Ins. Co. v. Kent, 73 F .2d 6 85, 6 85-8 7 (6th Cir. 1934) (holding
insured ’s death from intentionally pulling trigger of gun pointed at his presented evidence that during the course of her bending
head that he m istakenly thought was unloaded was accidental within the down to assist a patient, she “hypo” extended her knee.
meaning of a po licy that covered death from bodily injuries caused by Because Jones presented evidence that her injury was caused
“accidental means”); Md. Cas. Co. v. Massey, 38 F .2d 7 24, 7 25-2 7 (6th by an unintended and unexpected mishap, she has presented
Cir.), cert. denied, 282 U.S. 853 (1930) (holding that insured’s death evidence that her injury was caused by an accident.
brought about by infection resulting from wound caused by mishap when
insured intentionally pluck ed ha ir was acciden tal within the meaning of Additionally, Jones presented evidence that she did not
a policy that covered “death effected through accidental means”), with subjectively expect to injure her knee while bending down to
Landress v. Phoenix Mut. Life Ins. Co., 291 U.S. 491 , 495 -97 (1934) assist a patient during her normal work activities and that this
(holding that insured’s death brought about by sunstroke was not expectation was objectively reasonable. Because Jones
accidental within the meaning of a policy that covered death caused by presented evidence that her knee injury was neither
“external, violent and accidental mea ns” because insured intentionally
exposed himself to sun and there was no unforeseeable intervening force subjectively expected nor objectively foreseeable, Jones has
caused insured ’s death); Nickma n v. N.Y. Life Ins. Co., 39 F.2d 763, 764- presented evidence that she suffered an accidental injury.
65 (6th C ir.), cert. denied, 282 U.S. 855 (1930) (same ); Pope v.
Prudential Ins. Co. of Am., 29 F.2d 185, 185-86 (6th Cir. 1928) (holding In this case, MetLife added an eligibility requirement under
that insured’s death brought about by hemorrhage during operation was the guise of interpreting the term “accident” that does not
not accidental within the meaning of a policy that covered death from exist in either the Plan documents or federal common law;
“bodily injuries effected solely through external violence and accidental
causes” because insured intentionally underwent operation, it was not therefore, MetLife’s interpretation of the Plan is arbitrary and
uncommon for patients to hemorrhage during same operation, and there capricious. When denying Jones’s claim for PAI benefits,
was no evidence of a mishap during insured’s operation). MetLife applied an arbitrary-and-capricious definition of the
By citing cases that ap ply the accidental means versus accidental term “accident.” Moreover, in its May 7, 2001 denial of
results distinction we d o not intend to revive what may be a defunct Jones’s request for administrative review, MetLife indicated
distinction. Moreo ver, the P lan language does not indicate that it is an
accidental means po licy, but M etLife’s denial of benefit letters indicate
that it believes the plan contains some fo rm of “accide ntal means”
requirement. We note that although the P lan indicates that it will pay “for
all losses suffered by one covered individual resulting from o ne acciden t” following the accidental means versus accidental results distinction
J.A. at 333 (GM Plan), the Plan and the Summary Plan Description state because while there may be several definitions of the term “accident” that
that PAI benefits are award ed for “accid ental bodily injuries.” J.A. at 333 find support in federal law, the definition proffered by MetLife finds no
(GM Plan); J.A. at 88 (GM Summ. Plan Description). We cite cases such suppo rt.
No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 19
that it had not determined whether Jones was totally and
permanently disabled. Because application of the correct
definition of accident and the ultimate resolution of Jones’s
claim requires additional findings of fact, we will remand this
case to MetLife. Compare Univ. Hosps., 202 F.3d at 852,
with Williams v. Int’l Paper Co., 227 F.3d 706, 715-16 (6th
Cir. 2000).
III. CONCLUSION
For the foregoing reasons, we REVERSE the district
court’s order granting MetLife’s motion for judgment on the
administrative record and REMAND this case to the district
court with instructions to remand this claim to MetLife for
reconsideration of Jones’s medical evidence in light of this
opinion.