Opinion ID: 171456
Heading Depth: 1
Heading Rank: 2

Heading: Brad Kellogg's coverage under the Plan

Text: At the time of his death, Brad Kellogg was employed by Pfizer Incorporated (Pfizer) as a pharmaceutical sales representative and was a participant in the Pfizer Life Insurance and Accidental Death and Dismemberment (AD & D) Insurance Plans (the Plan), which was an ERISA-regulated employee welfare benefit plan. The Plan automatically provided each participant life insurance coverage equal to two times their annual pay. The Plan further allowed each participant the opportunity to elect additional life insurance coverage and one of ten AD & D insurance coverage options. Brad Kellogg elected to pay for additional life insurance and AD & D coverage in amounts equal to six times [his] annual pay, or approximately $438,000.00 each. Id. at 63. The AD & D provisions of the Certificate of Insurance provided, in pertinent part, as follows: If You 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 Covered Loss must be sent to Us. When We receive such Proof We will review the claim and, if We approve it, will pay the insurance in effect on the date of the injury. 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.    EXCLUSIONS We will not pay benefits under this section 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.... Id. at 293. The AD & D provisions of the Summary Plan Description (SPD) stated in similar, but not identical, fashion, that [i]f you [the participant] die as a result of, and within 12 months after, an accident, your beneficiary will receive 100 percent of your AD & D insurance coverage. Id. at 68. The SPD also stated that losses due to... physical or mental illness were excluded from AD & D coverage. Id. at 69.