Metropolitan Life Insurance v. Cotter
984 N.E.2d 835
Mass.2013Background
- Cotter held an own-occupation disability policy with a care requirement: benefits require care by a physician appropriate for the condition causing disability.
- MetLife paid Cotter disability benefits after his 2004 prostate cancer surgery and subsequent incontinence; Cotter later pursued alternate employment while receiving benefits.
- MetLife determined Cotter’s care was not appropriate because Weiss’ treatment focused on a return to a less stressful, alternate occupation, not Cotter’s prior occupation.
- MetLife notified Cotter it would continue benefits under a reservation of rights and filed suit for a declaration of no continuing obligation and potential reimbursement.
- Trial judge found Cotter was not receiving care appropriate for his condition and thus not entitled to benefits, while also ruling MetLife was not entitled to reimbursement; Cotter counterclaims under G. L. c. 93A and c. 176D were denied.
- This court concludes Cotter is not entitled to benefits and MetLife is not entitled to reimbursement, but on grounds different from the trial judge’s reasoning.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| What standard applies to 'appropriate for the condition causing the disability'? | Cotter asserts Weiss’s psychiatric care, generally appropriate for his condition, satisfies the clause. | MetLife contends the clause requires care aimed at enabling return to the prior occupation. | Appropriate care requires care designed to enable return to the prior occupation. |
| May insurer recover benefits paid under a unilateral reservation of rights when no explicit reimbursement provision exists? | MetLife seeks reimbursement for benefits paid under the reservation. | Cotter argues no contractual basis or unjust enrichment justification exists for repayment. | MetLife not entitled to reimbursement on the record; equitable/unjust enrichment burden not met. |
Key Cases Cited
- Heller v. Equitable Life Assur. Soc’y, 833 F.2d 1253 (7th Cir. 1987) (regular care vs. care appropriate for condition framework)
- Postma v. Paul Revere Life Ins. Co., 223 F.3d 533 (7th Cir. 2000) (care language interpreted to require appropriate care for condition)
- Mack v. Unum Life Ins. Co., 471 F. Supp. 2d 1285 (S.D. Fla. 2007) (duty to seek/accept care to enable return to prior occupation)
- Mutual Life Ins. Co. v. Ellison, 223 F.2d 686 (5th Cir. 1955) (early articulation of appropriate care concept)
- Lustenberger v. Boston Cas. Co., 300 Mass. 130 (1938) (regular care concept in Massachusetts context)