947 F. Supp. 2d 1163
N.D. Okla.2013Background
- ERISA action to recover AD&D benefits under MetLife policy in state court, removed to federal court.
- Death of Clifton Ingle from E. coli infection after food poisoning at Country Cottage, Oklahoma.
- Policy provides AD&D benefits of $120,000 and includes illness and infection exclusions.
- MetLife denied benefits, citing non-accidental death and the infection exclusion; later relied on illness exclusion.
- Court applies ERISA preemption and analyzes whether policy language excludes coverage for death caused by infection.
- Case proceeds to determine appropriate standard of review and application of exclusions to the death outcome.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standard of review for benefit determination | Ingle.argues de novo review given policy language | MetLife argues discretionary authority exists under policy | Infection/illness exclusions apply; arbitrary and capricious standard governs given language and Nance guidance. |
| Whether infection exclusion bars AD&D coverage | Death from foodborne illness should be covered as accident-related | Death caused by infection excluded unless infection from external wound | Infection exclusion bars recovery; death caused by infection not covered. |
| ERISA preemption of state-law doctrines urged by plaintiff | State doctrines (predominant cause) should apply under ERISA | State doctrines preempted; ERISA plan language controls | ERISA preempts state-law predominant-cause theories; policy language governs outcome. |
| Effect of plan language requiring proof satisfactory to MetLife | Language creates discretionary authority | Language does not negate ERISA discretion; allows review under arbitrary and capricious standard | Language supports arbitrary and capricious review; not under de novo due to Nance analysis. |
Key Cases Cited
- Nance v. Sun Life Assur. Co. of Canada, 294 F.3d 1263 (10th Cir. 2002) (distinguishes proof to whom satisfactory as determining discretionary review)
- Peckham v. Gem State Mut. of Utah, 964 F.2d 1043 (10th Cir. 1992) (ERISA preemption limits state-law modification of plan)
- Pirkheim v. First UNUM Life Ins. Co., 50 F. Supp. 2d 1018 (D. Colo. 1999) (ERISA preemption of state law where it would modify plan)
- Izzarelli v. Rexene Prods. Co., 24 F.3d 1506 (5th Cir. 1994) (standard of review not waivable in ERISA cases)
- Jones v. Metro. Life Ins. Co., 385 F.3d 654 (6th Cir. 2004) (discusses appellate standard of review in ERISA context)