Tommy Dowdy v. Metropolitan Life Ins. Co.
890 F.3d 802
9th Cir.2018Background
- In Sept. 2014 Tommy Dowdy was severely injured in a car crash; his left lower leg later required below‑knee amputation (Feb. 13, 2015) after infection and nonunion.
- Dowdy and his wife claimed accidental death & dismemberment (AD&D) benefits under an ERISA‑governed MetLife group policy through Bank of the West employment.
- The Plan pays for loss caused by an accidental injury that is the “Direct and Sole Cause” and excludes losses "caused or contributed to by ... illness or infirmity" and generally excludes infections unless occurring in an external accidental wound.
- MetLife first denied benefits as not a severance, then, after amputation, denied under the Illness/Infirmity Exclusion, asserting Dowdy’s diabetes contributed to nonhealing and infection.
- The Dowdys administratively appealed, sued under ERISA §502(a)(1)(B), and the district court (reviewing the administrative record) affirmed MetLife’s denial, finding diabetes substantially contributed to the loss.
- The Ninth Circuit reversed, holding the record does not show diabetes substantially caused or contributed to the amputation and remanded for calculation of benefits.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether court may consider extrinsic evidence beyond administrative record | Dowdy sought to introduce medical chart and other materials to support claim | MetLife relied on administrative record; district court excluded extrinsic evidence | Court affirmed exclusion was harmless: only the medical chart arguably relevant and it did not help plaintiff, so no reversible error |
| Whether accident was the “direct and sole cause” given preexisting diabetes | Dowdy: accident was predominant cause; diabetes at most complicated healing, not a substantial contributor | MetLife: diabetes contributed/complicated healing and thus negates ‘‘direct and sole’’ requirement | Held for Dowdy: even under the stricter substantial‑contribution standard, record does not show diabetes substantially contributed to need for amputation |
| Whether Illness/Infirmity Exclusion bars benefits because diabetes “caused or contributed” | Dowdy: exclusion must be strictly construed and MetLife bears burden; contribution must be substantial | MetLife: diabetes contributed to wound complications and infection, so exclusion applies | Held for Dowdy: exclusion inapplicable because MetLife failed to prove diabetes substantially caused or contributed to the loss |
| Remedy / next steps | Dowdy: entitlement to benefits and remand to calculate amount due | MetLife: (implicit) denial stands; remand unnecessary | Held: reversed and remanded to district court to determine benefits amount consistent with opinion |
Key Cases Cited
- McClure v. Life Ins. Co. of N. Am., 84 F.3d 1129 (9th Cir. 1996) (governs how preexisting conditions affect accident coverage; introduces substantial‑contribution analysis)
- Mongeluzo v. Baxter Travenol Long Term Disability Benefits Plan, 46 F.3d 938 (9th Cir. 1995) (circumstances permitting courts to consider evidence beyond administrative record)
- Quesinberry v. Life Ins. Co. of N. Am., 987 F.2d 1017 (4th Cir. 1993) (factors for adding extrinsic evidence to administrative record)
- Adkins v. Reliance Standard Life Ins. Co., 917 F.2d 794 (4th Cir. 1990) (pre‑disposition or susceptibility alone does not necessarily constitute substantial contributing cause)
- Silver v. Exec. Car Leasing Long‑Term Disability Plan, 466 F.3d 727 (9th Cir. 2006) (standard of review for district court factual findings in ERISA appeals)
- Opeta v. Nw. Airlines Pension Plan for Contract Emps., 484 F.3d 1211 (9th Cir. 2007) (abuse of discretion standard for district court’s decision to exclude extrinsic evidence)
- Padfield v. AIG Life Ins. Co., 290 F.3d 1121 (9th Cir. 2002) (federal common law governs ERISA plan interpretation)
- Evans v. Safeco Life Ins. Co., 916 F.2d 1437 (9th Cir. 1990) (federal common law framing for ERISA benefit disputes)