Opinion ID: 173034
Heading Depth: 2
Heading Rank: 3

Heading: MetLife's Claim Determination

Text: Ms. Hancock is her mother's Plan beneficiary. On January 20, 2005, MetLife received her claim for life and AD & D payments. It approved the claims under basic and optional coverage but denied AD & D benefits. Its March 22 notification letter to Ms. Hancock explained that because accidental death had not been established, she was ineligible for AD & D benefits. On May 19 Ms. Hancock sent MetLife a letter appealing the denial of AD & D benefits. She provided her own observations of the scene of death and reported on two conversations with those who had investigated the death: according to her letter, the investigating detective said that it looked like [Verla Hancock] slipped, fell, and hit her head, and the medical examiner told her that it was entirely possible that Verla Hancock slipped, fell and hit her head hard enough to render her unconscious but not hard enough to fracture her skull. Admin. R. at 174. MetLife denied her appeal on September 1. It characterized Ms. Hancock's evidence as conjecture and reiterated that she had not shown that her mother's death had been caused by an accident. Ms. Hancock obtained counsel and appealed again on February 6, 2006. This time she submitted copies of the police report, police photographs of the scene, autopsy documents, and an investigative report prepared by MRA Forensic Sciences, a firm she had hired. MetLife agreed to conduct further administrative review but had rendered no decision by June 27, when Ms. Hancock's counsel demanded that MetLife pay AD & D benefits within ten days or be sued. On September 12, 2006, still without word on her appeal, Ms. Hancock filed suit against MetLife in Utah state court, alleging breach of contract, breach of the duty of good faith and fair dealing, and other claims. One day later, MetLife sent her a letter reaffirming its denial of benefits. The case was later removed to federal court on MetLife's motion.