Opinion ID: 171456
Heading Depth: 1
Heading Rank: 3

Heading: Cherilyn Kellogg's claim for life and AD & D benefits

Text: On February 9, 2005, Kellogg's attorney submitted to Metropolitan Life Insurance Company (MetLife), the claims administrator, a formal claim for life and AD & D benefits under the Plan. On March 8, 2005, MetLife sent a letter to Kellogg's attorney stating that, [i]n order for [it] to consider the claim for [AD & D] insurance benefits, it require[d] a Copy of the Police Report, a Copy of the Autopsy Report, a Copy of the Toxicology Report, and Newspaper clippings. Id. at 116. On March 25, 2005, MetLife sent a letter to Stephen Morris, a deputy coroner with the Merced County Sheriff's Department, asking for [a] written statement by the medical examiner/coroner on their letterhead stating the manner of [Brad Kellogg's] death. Id. at 113. On March 30, 2005, Morris sent a letter back to MetLife, on Sheriff's Department letterhead, stating as follows: Brad Kellogg (DOB 07/12/1968), expired on 09/06/2004 at Mercy Medical Center, Community Campus in the city of Merced in Merced County California. Mr. Kellogg's death is not the result of a homicide or suicide. He died as the result of traumatic injuries sustained in a solo motor vehicle accident. His death is considered to be accidental. Id. at 109. On May 10, 2005, MetLife approved Kellogg's claim for life insurance benefits under the Plan. On that same date, MetLife sent a letter to Kellogg's attorney addressing the issue of AD & D benefits and stating, in pertinent part: In order for us to consider the claim for Accidental Death and Dismemberment Accidental insurance benefits, we will require the following:  Copy of the Police Report  Copy of the Autopsy Report  Copy of the Toxicology Report/Toxicology Report  Newspaper clippings (if available) Id. at 87. On June 9, 2005, Kellogg's counsel forwarded to MetLife (i) the final Certificate of Death; (ii) a copy of the police report; (iii) a copy of the autopsy report; (iv) a copy of the toxicology report; and (v) the newspaper clippings that were in Mrs. Kellogg's possession. Id. at 166. Along with the documents, counsel sent a one-page letter to MetLife stating: Now that you have the requested documentation, please consider this our formal request to pay the balance of the life insurance proceeds, representing the payment of accidental death and dismemberment proceeds, to Mrs. Kellogg. Id. On June 22, 2005, MetLife personnel obtained information, via a web site called WebMDHealth, regarding the medications that the toxicology report found in Brad Kellogg's system at the time of his death. There is no indication in the administrative record that any medically-trained personnel were involved in this search or reviewed the search results. On June 29, 2005, MetLife sent a letter to Kellogg's counsel stating as follows: We are writing in regard to the A D & D benefits that have been submitted. It will be necessary for us to evaluate this portion of the claim, therefore, completion of this claim will be delayed for a short period of time. When a decision has been made, we will notify you of our findings in a timely manner. Id. at 156. On July 6, 2005, Kellogg's counsel responded to MetLife's June 29, 2005 letter, stating in pertinent part: Thank you for your status letter dated June 29, 2005. Would it be possible for you to explain exactly what issues require further evaluation? Mr. Kellogg's death was determined to be an accident. What exclusions, if any in the policy, give your company reasons for concern?    Please let me know what, if any, issues MetLife is concerned about. Id. at 155. MetLife did not, however, respond to Kellogg's counsel's request. On October 26, 2005, Kellogg's counsel sent another letter to MetLife expressing frustration with its delay in resolving the claim for AD & D benefits and threatening to file suit if MetLife did not reach a decision soon. On November 17, 2005, MetLife sent a letter to Kellogg's counsel denying her claim for AD & D benefits. Id. at 129. The letter stated: We have evaluated your client's claim for the referenced benefits. For the reasons detailed below, we must deny your client's claim. The plan is an employee welfare benefit plan regulated by the Employee Retirement Income Security Act of 1974, as amended (ERISA), 29 U.S.C. § § 1001-1461. MetLife, as claim fiduciary, must administer claims in accordance with ERISA and the documents and instruments governing the plan. The Plan states that Accidental Death and Dismemberment (AD & D) benefits are payable if a plan participant dies as a result of an accident. Summary Plan Description at page 10. It goes on to state that, The Pfizer AD & D Insurance Plan does not cover losses due to:... physical ... illness. Summary Plan Description at page 12. The police report submitted to us states that, according to a witness to the crash, after taking off from a stop sign, the decedent's vehicle veered into a tree. The witness stated that it appeared the decedent was having a seizure. She saw no attempt by the decedent to brake or avoid the tree. The police could find no other cause for the crash. Under the terms of the plan, AD & D benefits are not payable if a loss is due to physical illness. The decedent's physical illness, the seizure, was the cause of the crash. Accordingly, we must deny your claim. Under ERISA, your client has the right to appeal this decision within sixty (60) days after the receipt of this letter. To do so, you must submit a written request for appeal to MetLife at the address above. Please include in the appeal letter the reason(s) you believe the claim was improperly denied, and submit any additional comments, documents, records or other information relating to your claim that you deem appropriate to enable MetLife to give your client's appeal proper consideration. Upon your written request, MetLife will provide you with a copy of the records and/or reports that are relevant to your client's claim. MetLife will carefully evaluate all the information and advise you of its decision within sixty (60) days after the receipt of your client's appeal. If there are special circumstances requiring additional time to complete the review, we may take up to an additional sixty (60) days, but only after notifying you of the special circumstances in writing. In the event your client's appeal is denied in whole or in part, you have the right to bring a civil action under Section 502(a) of ERISA, 29 U.S.C. § 1132(a). Id. at 129-30.