United States Court of Appeals

for the Fifth Circuit ____________

No. 23-11247

____________

Fonda Wicks, 

Plaintiff—Appellant, 

versus

Metropolitan Life Insurance Company, 

Defendant—Appellee. 

______________________________

Appeal from the United States District Court 

for the Northern District of Texas

USDC No. 4:21-CV-1275 

______________________________

Before King, Stewart, and Higginson, Circuit Judges.

Per Curiam:*

Plaintiff-Appellant Fonda Wicks (“Wicks”) appeals the district 

court’s judgment in favor of Defendant-Appellee Metropolitan Life 

Insurance Company (“MetLife”) upholding MetLife’s denial of accidental 

death benefits after Wicks’s husband died while recovering in the hospital 

from gastric sleeve surgery. For the reasons that follow, we AFFIRM the 

district court’s judgment in favor of MetLife. 

_____________________

* This opinion is not designated for publication. See 5th Cir. R. 47.5.

United States Court of Appeals

Fifth Circuit

FILED

September 17, 2024

Lyle W. Cayce

Clerk

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I. FACTUAL & PROCEDURAL BACKGROUND

The plaintiff-appellant in this case, Wicks, is the widow of decedent 

Jackie Wicks (“Mr. Wicks”). On June 24, 2021, Mr. Wicks was admitted to 

Lake Granbury Medical Center and underwent a robotic-assisted 

laparoscopic sleeve gastrectomy, commonly referred to as gastric sleeve 

surgery. At the time of the surgery, Mr. Wicks was sixty years old with a 

history of morbid obesity and obstructive sleep apnea. The gastric sleeve 

surgery was completed successfully without complications. 

While in recovery, Mr. Wicks was prescribed several pain medications 

to be administered intravenously, including morphine, fentanyl, and 

hydromorphine, i.e., Dilaudid. He received 50 micrograms of fentanyl at 

11:02 a.m. and at 11:06 a.m. and 4 milligrams of morphine at 11:20 a.m. He 

was moved from the recovery unit to a hospital room at approximately 12:30 

p.m. Once in his hospital room, he ambulated (or walked) up and down the 

hall with assistance, but he complained of pain, so he was given 1 milligram 

of Dilaudid. Wicks then left Mr. Wicks’s room to get lunch and returned to 

find Mr. Wicks unresponsive and not breathing. At 1:38 p.m., a “Code Blue” 

was called, and hospital staff began to attempt life-saving procedures. At 1:40 

p.m. Mr. Wicks was given 2 milligrams of Narcan, which is a medication 

administered to reverse the effects of narcotics, but the Narcan had no effect. 

He was then moved to the Intensive Care Unit. Mr. Wicks died two days 

later, on June 26, 2021. 

Dr. Tara Pavelek pronounced Mr. Wicks dead and prepared the death 

certificate. According to the death certificate, the manner of death was 

“natural,” and the immediate cause of death was “anoxic brain injury” 

resulting from “cardiac arrest” and “aspiration of gastric contents,” with 

the underlying cause listed as “unintentional narcotic overdose.” Dr. 

Pavelek also listed on the death certificate “morbid obesity” and “severe 

obstructive sleep apnea” as “significant conditions contributing to death but 

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3

not resulting in the underlying cause” of death. An autopsy report was 

subsequently prepared by Dr. Paul Radelat. The report provided that Mr. 

Wicks “[e]xhibited anatomical changes in the brain consistent with a recent 

hypoxic or anoxic episode. Absent other causes, this is considered the 

immediate cause of death.” 

Prior to his death, Mr. Wicks participated as a company employee in 

a COG Operating LLC Welfare Benefit Plan (“Plan”). Mr. Wicks’s Plan is 

governed by the Employee Retirement Income Security Act (“ERISA”) of 

1974, as amended, 29 U.S.C. § 1001, et seq. MetLife is the administrator of 

the Plan. Wicks is the sole beneficiary of the coverages under the Plan. 

Under the Plan’s terms, Mr. Wicks was enrolled in basic life 

insurance, accidental death and dismemberment (“AD&D”), and voluntary 

AD&D coverage. Only the two AD&D provisions are at issue in this appeal. 

The insurance provisions for these coverages are essentially identical and 

provide:

If You [or a Dependent]1 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 the Covered Loss must be 

sent to [MetLife]. When We receive such Proof We 

will review the claim. If We approve the claim, We will 

pay the insurance in effect on the date of the injury 

within 60 days of Our receipt of such proof.

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.

_____________________

1 The phrase “or a Dependent” is the primary variation between the two AD&D 

coverage descriptions.

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Under the Plan, “Proof” means written evidence, satisfactory to MetLife, 

that the claimant has satisfied the conditions and requirements for payment 

of any benefit described in the Plan, and “Covered Loss” includes “Loss of 

life.” 

Relevant herein, both AD&D coverages have two exclusion 

provisions: Exclusions 1 and 8. Exclusion 1, the “Illness/Treatment 

Exclusion,” states that benefits will not be paid “for any loss caused or 

contributed to by: 1. physical or mental illness or infirmity, or the diagnosis 

or treatment of such illness or infirmity.” Exclusion 8, the “Drug

Exclusion,” states that no benefits will be paid “for any loss caused or 

contributed to by . . . 8. the voluntary intake or use by any means of: any drug, 

medication or sedative, unless it is: taken or used as prescribed by a 

Physician.” 

After Mr. Wicks’s death, Wicks filed a claim for the basic life 

insurance benefits payable under the Plan. In July 2021, MetLife paid the 

benefits to Wicks in accordance with the Plan’s terms. Wicks also contacted 

MetLife about the AD&D benefits under the Plan but did not file an official 

claim for those benefits at that time. Instead, on October 7, 2021, Wicks filed 

a lawsuit against MetLife in the 355th Judicial District Court of Hood 

County, Texas. MetLife removed the lawsuit to federal court in November 

2021. Then, on November 24, 2021, pursuant to MetLife’s motion, the 

district court stayed the case to permit Wicks to exhaust her administrative 

remedies by submitting her claim to MetLife for the AD&D benefits under 

the Plan. 

Once the court case was administratively closed, Wicks submitted her 

AD&D claim to MetLife. MetLife denied Wicks’s AD&D claim in a letter 

dated March 9, 2022. In the denial letter, MetLife cited to the Plan’s insuring 

provision, the “Direct and Sole Cause” provision, and the 

“Illness/Treatment Exclusion,” and stated that, based on the terms of the 

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Plan and the facts in the administrative record, it had concluded that Mr. 

Wicks’s death was not a covered loss under the AD&D provisions in the Plan. 

MetLife explained that:

[T]he loss did not directly and solely result from an 

accidental injury. Rather, the death resulted from 

complications following surgery, which Mr. Wicks 

underwent to treat his morbid obesity. There is no 

indication of an accident, certainly not one that was 

independent of other causes. Consequently, the death 

was not a Covered Loss. 

MetLife continued that:

Even if an accident independent of other causes had 

occurred, which is not proven by the documents, the 

Plan excludes as a Covered Loss any loss which is 

caused or contributed to by physical illness or 

infirmity, or the diagnosis or treatment of such illness 

or infirmity. The facts here fall within this exclusion as 

Mr. Wicks’[s] death stemmed from his morbid 

obesity; his election to undergo surgical treatment to 

treat his morbid obesity; and the admission of 

hydromorphone to treat the related pain from the 

surgery. Clearly, Mr. Wicks’[s] physical condition 

and/or the medical treatment thereof caused or 

contributed to his death.

Following MetLife’s initial denial letter, Wicks filed an administrative 

appeal, this time contending that Mr. Wicks’s death was caused by a 

negligent overdose of prescription medications. 

In a letter dated July 13, 2022, MetLife upheld its initial denial of 

Wicks’s AD&D claim. In the second denial letter, MetLife again referenced 

the direct and sole cause provision, the illness/treatment exclusion, and the 

death certificate findings. MetLife then explained that it stood by its 

determination, stating that:

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[T]he loss was not a covered accident because it did 

not directly and solely result from an accidental injury. 

Rather, the loss was due to complications associated 

with medical treatment for obesity. Even assuming 

that Mr. Wicks’[s] loss falls within the covered 

accident provision, Accidental Death benefits are still 

not payable because the illness/treatment exclusion 

applies. Mr. Wicks’[s] obesity was a physical illness 

and when he underwent gastric sleeve surgery, he was 

receiving treatment to correct that illness. Further, the 

postoperative services that he received, which caused 

his death, were a necessary component of the gastric 

sleeve surgery. In short, Mr. Wicks died from his 

illness or as a direct result of medical treatment for his 

illness, which excluded the payment of Accidental 

Death benefits.

MetLife further provided the report of an independent medical expert, Dr. 

Michael Darracq, who had reviewed the medical documentation submitted 

by Wicks in support of her appeal. Based on his review of the documentation 

in the administrative record, Dr. Darracq stated that he could not conclude 

“with a reasonable degree of medical certainty that the loss [i.e., Mr. Wicks’s 

death] was solely due to an overdose of administered drugs.” Dr. Darracq 

further opined that “[a]n overdose did not take place in the present case. The 

decedent received an appropriate dose of medication and suffered an event 

in a timeframe that would not [be] reasonably anticipated from the 

administered drug alone.” Dr. Darracq concluded that Mr. Wicks:

had the physical illness of obesity [and i]n the absence 

of this condition and the surgery that was performed 

to correct it, [Mr. Wicks] would not have received 

postoperative medications that may have been 

contributory to death. Therefore, the loss was 

contributed to by the physical illness of obesity and the 

surgical treatment of same. 

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With MetLife’s denial of Wicks’s administrative appeal, the district 

court lifted the stay, and the legal proceedings continued. Once the case was 

reopened, both Wicks and MetLife moved for summary judgment. MetLife

alternatively moved for judgment on the administrative record. 

On August 14, 2023, the district court denied both Wicks’s and 

MetLife’s summary judgment motions based on its conclusion that 

“summary judgment [was] not the appropriate vehicle for resolution of this 

case due to the prevalence of disputed issues of fact.” The court then 

conducted a de novo review of the administrative record and upheld 

MetLife’s denial of benefits to Wicks, agreeing that she had failed to carry 

her burden of establishing that she was entitled to AD&D coverage based on 

the terms of the Plan. In its Memorandum Opinion & Order, the district court 

summarized its decision as follows:

[B]ecause the record shows that Mr. Wicks received 

an appropriate dosage of Dilaudid, the [c]ourt finds 

that Mr. Wicks received proper medical treatment. 

Since Mr. Wicks received proper medical treatment, 

the [c]ourt finds that his death was caused by the 

preexisting infirmity of obesity. Because Mr. Wicks 

died from obesity, his death did not result from 

“accidental injury, independent of other causes.” As 

such, an “Unintentional Narcotic Overdose” is not 

the Direct and Sole Cause of Mr. Wicks’[s] death. 

Given its holding that Wicks failed to show that the “unintentional narcotic 

overdose” was the “direct and sole cause” of Mr. Wicks’s death, the district 

court declined to address Wicks’s arguments related to the Plan’s drug 

exclusion and the exception contained therein. Wicks filed this appeal.

II. STANDARD OF REVIEW

ERISA provides federal courts with jurisdiction to review benefit 

determinations. See Ariana M. v. Humana Health Plan of Tex., Inc., 884 F.3d 

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246, 256–57 (5th Cir. 2018); 29 U.S.C. § 1132(a)(1)(B) (“A civil action may 

be brought . . . to recover benefits due to [a claimant] under the terms of his 

plan, to enforce his rights under the terms of the plan, or to clarify his rights 

to future benefits under the terms of the plan.”). Here, the district court 

conducted a de novo review of the administrative record under Federal Rule 

of Procedure 52(a). See FED. R. CIV. P. 52(a); Ariana M., 884 F.3d at 256–

57. Our review on appeal is also de novo. See Green v. Life Ins. Co. of N. Am., 

754 F.3d 324, 329 (5th Cir. 2014); Newsom v. Reliance Std. Life Ins. Co., 26 

F.4th 329, 334 (5th Cir. 2022); Miller v. Reliance Std. Life Ins. Co., 999 F.3d 

280, 283 (5th Cir. 2021).

2

On appeal, “we will not set aside the district court’s factual findings 

unless they are clearly erroneous.” Newsom, 26 F.4th at 334; FED. R. CIV.

P. 52(a)(6). “This is a high standard, meaning [w]e will not conclude that a 

district court’s finding of fact was clearly erroneous based only on our belief 

that, had [we] been sitting as the trier of fact, [we] would have weighed the 

evidence differently and made a different finding.” Id. at 335 (internal 

quotation marks and citation omitted). Thus, “[w]e will only reverse if a 

review of all the evidence leaves us with the definite and firm conviction that 

a mistake has been committed.” Id. (internal quotation marks and citation 

omitted).

III. DISCUSSION

_____________________

2 The district court determined that a de novo standard of review applied to 

MetLife’s benefits denial based on this court’s analysis in Ariana M., 884 F.3d at 256–57,

as well as various district court cases that have held that the Texas Insurance Code prevents 

application of ERISA’s discretionary clause. Neither party disputes that the de novo 

standard of review applies on appeal. Moreover, because Wicks’s claims still fail under the 

more lenient de novo review standard, it is unnecessary to analyze whether the abuse-ofdiscretion standard could apply herein. 

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On appeal, Wicks argues that when an insurer denies accidental death 

benefits due to obesity as violating the direct and sole cause clause, the death 

should “be naturally flowing from obesity or closely related to obesity.” 

Additionally, Wicks makes the following five arguments related to the 

exception contained in the Plan’s drug exclusion: (1) that she is entitled to 

benefits under the exception to the drug exclusion because Mr. Wicks died 

from an unintentional drug overdose after being administered narcotics that 

were prescribed by a physician at the hospital; (2) because the term 

“accident” is not defined in the Plan, the exception to the drug exclusion 

prevents the exclusion from applying or alternatively, a death resulting from 

a prescribed drug is designated an accident per the exception; (3) the Plan

requires that the medical treatment be negligent for the drug exception to 

apply “unless it is taken or used as prescribed by a physician”; (4) there is an 

ambiguity between the Plan’s drug exclusion and the exception thereto; and 

(5) there is an ambiguity between the Plan’s “direct and sole cause” clause 

and the drug exclusion’s exception. 

MetLife counters that to be entitled to AD&D benefits, Wicks was 

required to prove that there was coverage under the Plan’s insuring 

provision, i.e., that the post-operative narcotics that were administered to 

Mr. Wicks were the direct and sole cause of his death. Because Wicks failed 

to meet this burden, MetLife urges, the district court did not err in upholding 

MetLife’s denial of benefits. MetLife further contends that the district court 

did not err in declining to address the drug exclusion’s exception because 

Wicks’s AD&D claim was not covered under the terms of the Plan and an 

exception to an exclusion alone cannot create coverage. We agree with 

MetLife.

“ERISA’s principal function [is] to protect contractually defined 

benefits.” US Airways, Inc. v. McCutchen, 569 U.S. 88, 100 (2013) (internal 

quotation marks and citation omitted). ERISA’s statutory scheme is thus 

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“built around reliance on the face of written plan documents.” Id. at 100-01 

(citation omitted). “[A]n administrator must act in accordance with the 

documents and instruments governing the plan insofar as they accord with 

the statute[.]” Id. at 101. “The plan, in short, is at the center of ERISA.” Id.

“Federal common law governs rights and obligations stemming from 

ERISA-regulated plans, including the interpretation of policy provisions[.]” 

Green, 754 F.3d at 331 (internal quotation marks and citation omitted).

“When construing ERISA plan provisions, courts are to give the language of 

an insurance contract its ordinary and generally accepted meaning if such a 

meaning exists.” Green, 754 F.3d at 331; Newsom, 26 F.4th at 334. “Only if 

the plan terms remain ambiguous after applying ordinary principles of 

contract interpretation are we compelled to apply the rule of contra 

proferentum and construe the terms strictly in favor of the insured.” Green, 

754 F.3d at 331; Newsom, 26 F.4th at 334–35.

As an initial matter, because Wicks is a claimant seeking benefits 

under an ERISA plan, she bears the burden of proving entitlement to those 

benefits. See Perdue v. Burger King Corp., 7 F.3d 1251, 1254 n.9 (5th Cir. 1993).

Beginning with the terms of the Plan, to obtain AD&D coverage, Wicks was 

required to show that Mr. Wicks “sustain[ed] an accidental injury that [was] 

the Direct and Sole Cause of a Covered Loss,” with “Direct and Sole Cause” 

being defined as a “Covered Loss” that “was a direct result of the accidental 

injury, independent of other causes.” Although Wicks was able to point to 

language in the death certificate that Dr. Pavelek concluded that Mr. Wicks’s 

death was caused in part by the post-operative narcotics he received, Wicks 

failed to provide evidence that the narcotics were the “Direct and Sole 

Cause” of the “Covered Loss,” i.e., Mr. Wicks’s death. 

As the district court reasoned, it was not necessary for it to define the 

term “accident” in this case. Regardless of whether Mr. Wicks sustained an 

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“accidental injury” that was a “covered loss,” Wicks failed to show that the 

covered loss was a direct result of an “accidental injury” that was 

“independent of other causes” (his morbid obesity). Consequently, she 

could not show entitlement to AD&D coverage because the terms of the Plan 

required that the accidental injury be the “direct and sole” cause of the 

covered loss. As explained below, the district court’s reasoning is supported 

by applicable caselaw as well as the medical expert reports and other evidence 

in the administrative record when read in the context of the terms in the Plan. 

In support of its analysis regarding the direct and sole cause clause in 

the Plan, the district court pointed to Fifth Circuit precedent holding that

“the standard complications of standard medical treatment” for obesity were 

the foreseeable result of treatment for the disease rather than a covered 

accident. See Thomas v. AIG Life Ins. Co., 244 F.3d 368, 369–70 (5th Cir. 

2001) (quoting Senkier v. Hartford Life & Accident Ins. Co., 948 F.2d 1050, 

1053 (7th Cir. 1991)). In Thomas, this court evaluated a case factually similar 

to the one herein where the decedent suffered from morbid obesity, had two 

stomach stapling surgeries to treat his disease, and ultimately died from 

sepsis after his sutures ruptured following his second surgery. Id. at 369. 

There, the panel explained that there was no “principled basis on which to 

disassociate [the decedent’s] iatrogenic injury from the disease 

complications of his obesity,” ultimately concluding that “his death was the 

foreseeable result of treatment for his disease.” Id. at 370. On those grounds, 

the panel concluded that “the plan administrator did not abuse its discretion 

in finding that [the decedent’s] injury was attributable to a disease rather than 

an accident under the accidental death policies.” Id. In reaching its 

conclusion, the panel relied on the Seventh Circuit’s reasoning in Senkier

explaining that when death results because proper medical treatment is 

unsuccessful, the death is caused by the preexisting infirmity. See Senkier, 

948 F.2d at 1053 (“When you die from the standard complications of 

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standard medical treatments you don’t, it seems to us, die in or because of an 

accident; your death is the result of illness.”). 

The panel’s reasoning in Thomas is persuasive here given that both 

cases involved decedents with preexisting infirmities of morbid obesity that 

underwent surgery to treat their diseases and subsequently suffered postoperative complications after receiving proper medical treatment that 

resulted in their deaths. Moreover, because Thomas is also controlling circuit 

precedent, it was reasonable for the district court to rely on it in reaching its 

conclusion that Wicks failed to show that an accidental injury was the “sole 

and direct cause” of Mr. Wicks’s death due to his preexisting infirmity of 

morbid obesity. Additionally, given the Thomas panel’s adoption of the 

Seventh Circuit’s reasoning in Senkier, the district court was also entitled to 

conclude that because Mr. Wicks received proper medical treatment and 

death nevertheless resulted, his death was caused by the preexisting infirmity 

of his obesity. See Senkier, 948 F.2d at 1053.3

In further support of its analysis, the district court cited to Koch, a 

district court case where the court addressed the same “Direct and Sole 

Cause” clause that is at issue in Wicks’s case. See Koch v. Metro. Life Ins. Co., 

425 F. Supp. 3d 741, 744 (N.D. Tex. 2019). There, the district court noted 

that there was evidence presented which showed that the decedent’s death 

was caused by a fall but there was also evidence showing that his death was 

_____________________

3 Although Wicks takes issue on appeal with the district court’s reliance on caselaw 

to aid in its interpretation of the Plan provisions, her position is unfounded as this court has 

consistently held that “[f]ederal common law governs rights and obligations stemming 

from ERISA-regulated plans, including the interpretation of policy provisions[.]” Green, 

754 F.3d at 331 (internal quotation marks and citation omitted). We further reject Wicks’s

argument that Mr. Wicks was entitled to receive copies of the potential cases relied on by 

the district court before purchasing the Plan. Wick points to no statutory or other legal 

authority in support of her argument, nor would any such requirement be feasible given 

that caselaw by its nature is constantly evolving. 

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caused by a heart attack. Id. at 751. For that reason, the district court 

determined that the claimant failed to carry her burden of establishing 

entitlement to accidental death benefits under the ERISA plan because she 

could not show that the decedent’s fall was the “direct and sole cause” of his 

death. Id.

Although not controlling, the district court’s reasoning in Koch is 

persuasive here given the factual similarities between the two cases, i.e., both 

cases featured two potential causes leading to the decedent’s death and thus, 

neither one could be considered the “direct and sole cause” of the death. It 

is irrelevant that the two potential causes of the decedent’s death in Koch (a 

heart attack and a fall) were different from the two potential causes of death 

in Wicks’s case (a preexisting infirmity of morbid obesity and post-operative 

narcotics). Simply put, the reasoning in Koch supports the conclusion that 

when evidence is presented of two potential causes, the claimant must show 

that the covered cause (the accidental injury) was the direct and sole cause of 

the loss (the decedent’s death) to obtain the AD&D coverage. This is 

something that, like the claimant in Koch, Wicks was unable to do. Thus, the 

district court did not err in partially relying on the reasoning in Koch to 

conclude that Wicks failed to carry her burden of establishing that Mr. 

Wicks’s death was caused solely and directly by an accidental injury, given 

his preexisting infirmity of morbid obesity. Id. 

The record further reveals that the district court did not solely rely on 

the Koch and Thomas cases in reaching its determination that Wicks failed to 

show her entitlement to AD&D benefits under the Plan. It also relied on the 

report of Dr. Darracq, MetLife’s medical expert, who stated that he could 

not conclude “with a reasonable degree of medical certainty that the loss [i.e., 

Mr. Wicks’s death] was solely due to an overdose of administered drugs.” 

Indeed, Dr. Darracq went so far as to opine that there was no overdose at all 

in this case, stating that “[t]he decedent received an appropriate dose of 

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medication and suffered an event in a timeframe that would not [be] 

reasonably anticipated from the administered drug alone.” As the district 

court noted, Dr. Darracq also observed that Mr. Wicks “had the physical 

illness of obesity [and i]n the absence of this condition and the surgery that 

was performed to correct it, [he] would not have received postoperative 

medications that may have been contributory to death. Therefore, the loss 

was contributed to by the physical illness of obesity and the surgical treatment 

of same.” 

We agree that Dr. Darracq’s expert report adequately supports the 

district court’s determinations that: (1) Mr. Wicks received an appropriate 

dosage of Dilaudid, and thus received proper medical treatment; (2) given 

that Mr. Wicks received proper medical treatment, his death was caused by 

the preexisting infirmity of obesity; and (3) because Mr. Wicks died from 

obesity, his death did not result from “accidental injury, independent of 

other causes.” Consequently, it was reasonable for the district court to 

conclude under Thomas that, because the standard complications of standard 

medical treatment for obesity were the foreseeable result of treatment for his

disease rather than a covered accident, Wicks was not entitled to AD&D 

coverage under the plan. See Thomas, 244 F.3d at 369–70 (quoting Senkier, 

948 F.2d at 1053). Moreover, as the district court accurately observed, 

although Wicks submitted evidence of several other medical experts involved 

in the case (Drs. Belott, Zheng, Radelat, and Pavelek), the reports and 

documentation submitted by these doctors did not controvert or dispute Dr. 

Darracq’s findings. In other words, none spoke to the issue of whether the 

post-operative narcotics were the direct and sole cause of Mr. Wicks’s death, 

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nor did they contradict Dr. Darracq’s conclusion that Mr. Wicks’s morbid 

obesity, not the narcotics, was the underlying cause of his death.4

In light of the above analysis, we conclude that there is no merit to 

Wicks’s argument on appeal that when an insurer denies accidental death 

benefits due to obesity as violating the direct and sole cause clause, the death 

should “be naturally flowing from obesity or closely related to obesity.” Her 

argument not only misconstrues the applicable law, it also misinterprets the 

district court’s holding as it relates to the terms of the Plan. 

Finally, although the record indicates that MetLife cited to the 

illness/treatment exclusions under the Plan in both of its denial letters to 

Wicks, the district court declined to address the exclusions in the 

proceedings below based on its finding that Wicks failed to show that 

coverage existed under the terms of the Plan in the first place. On appeal, 

MetLife supports the district court’s decision not to address the exclusions 

and argues that because Wicks has failed to show entitlement to AD&D 

coverage under the terms of the Plan, she likewise cannot show entitlement 

to AD&D coverage through any of the Plan’s exclusions or exceptions 

thereto. Wicks, on the other hand, devotesfive of her six arguments on appeal 

to a discussion of the exclusions in the Plan, arguing that the prescription 

drug exception to the illness/treatment exclusions shows that her AD&D 

claims are covered under the terms of the Plan. Her arguments, however, do 

not survive under our longstanding precedent. 

_____________________

4 As the district court pointed out, Wicks “provide[d] no competent expert 

testimony showing that the doctor inappropriately prescribed an excessive amount of 

Dilaudid or that the nurses failed to follow the prescription.” 

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As this court has consistently held, “an exclusion cannot create 

coverage that would not otherwise exist under a policy.” See Columbia Cas. 

Co. v. Ga. & Fla. RailNet, Inc., 542 F.3d 106, 112 (5th Cir. 2008) (citing United 

Nat’l Ins. Co. v. Hydro Tank, Inc., 497 F.3d 445, 452–53 (5th Cir. 2007)); see 

also Sw. Airlines Co. v. Liberty Ins. Underwriters, Inc., 90 F.4th 847, 855 (5th 

Cir. 2024) (“[A] policy’s main insuring clause sets the boundaries of 

coverage while its exclusions ‘subtract’ from that coverage.”). For this 

reason, a claimant is required to establish that a claim is covered under the 

insuring clause of the policy before exclusions or exceptions can be invoked. 

See Martin Res. Mgmt. Corp. v. Fed. Ins. Co., 2021 WL 4269565, at *5 (5th Cir. 

Sept. 20, 2021) (unpublished) (citing Mary Kay Hldg. Corp. v. Fed. Ins. Co., 

309 F. App’x 843, 850 n.5 (5th Cir. 2009) (unpublished) (“[E]xceptions to 

exclusions do not, in themselves, yield insurance coverage.”)). 

Here, because the administrative record and applicable law support 

the district court’s determination that Wicks failed to carry her burden of 

establishing her entitlement to AD&D coverage under the terms of the Plan,

the district court did not err in declining to address her arguments on these

issues. For the same reasons, we reject her arguments on appeal that she is 

entitled to coverage through one or more of the Plan’s exclusions, or 

exceptions thereto. See Columbia Cas. Co., 542 F.3d at 112 (citing United 

Nat’l Ins. Co., 497 F.3d at 452–53); see also Smith v. Am. Family Life Assurance 

Co. of Columbus, 584 F.3d 212, 218 (5th Cir. 2009) (“In the insurance 

context, an ‘exclusion’ is a ‘provision that excepts certain events or 

Case: 23-11247 Document: 47-1 Page: 16 Date Filed: 09/17/2024
No. 23-11247

17

conditions from [previously established] coverage.’” (quoting BLACK’S 

LAW DICTIONARY (8th ed. 2004))).5

In sum, the terms of the Plan, the administrative record, and the 

applicable law adequately support the district court’s holding that Wicks 

failed to carry her burden of proving that an “accidental injury” was the 

“direct and sole cause” of Mr. Wicks’s death. Accordingly, we affirm the

district court’s judgment upholding MetLife’s denial of AD&D coverage in 

this case.6

IV. CONCLUSION

The district court’s judgment is AFFIRMED.

_____________________

5 For these reasons, we also decline to address Wicks’s arguments that an 

ambiguity exists between the drug treatment exception and exclusion thereto and that 

another ambiguity exists between the direct and sole cause clause and the language in the 

drug treatment exception. Because she is again relying on arguments relating to one of the 

exceptions to the exclusions in the Plan to support her position regarding resolving 

ambiguities in favor of the insured, and it has been affirmatively established herein supra 

through controlling precedent that she cannot show entitlement to coverage through the 

Plan’s exclusions or exceptions thereto,we need not address the issue further. For the same 

reason, it is unnecessary that we address her argument that there is a public policy against 

drug exclusions and/or exceptions thereto. 

6 We also note that Wicks makes a number of miscellaneous arguments throughout 

her brief on appeal such as: (1) the district court added terms not in the Plan and failed to 

interpret and give meaning to the relevant clauses in the Plan; (2) the district court failed 

to define “accident or accidental injury” in the Plan; and (3) Mr. Wicks’s accidental injury 

was anoxic brain injury, and the covered loss was death, so the brain injury was the sole and 

direct cause of the death. In light of our conclusion that the district court did not err in 

holding that Wicks failed to carry her burden of proving that an “accidental injury” was 

the “direct and sole cause” of Mr. Wicks’s death, it is unnecessary that we address her 

additional miscellaneous arguments herein.

Case: 23-11247 Document: 47-1 Page: 17 Date Filed: 09/17/2024