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

Heading: MetLife's Benefit Denial

Text: Having determined the proper standard of review, we turn to the second issue before us: whether MetLife's denial of Ms. Hancock's AD & D claim was arbitrary and capricious. Indicia of arbitrary and capricious decisions include lack of substantial evidence, mistake of law, bad faith, and conflict of interest by the fiduciary. Caldwell v. Life Ins. Co. of N. Am., 287 F.3d 1276, 1282 (10th Cir.2002). To survive our review, MetLife's decision need not be the only logical one nor even the best one. It need only be sufficiently supported by facts within [its] knowledge to counter a claim that it was arbitrary or capricious. The decision will be upheld unless it is not grounded on any reasonable basis. Finley v. Hewlett-Packard Co. Employee Benefits Org. Income Prot. Plan, 379 F.3d 1168, 1176 (10th Cir.2004) (internal quotation marks omitted). As the claimant, Ms. Hancock bore the burden of proving the occurrence of a covered loss. See McGee v. Equicor-Equitable HCA Corp., 953 F.2d 1192, 1205 (10th Cir.1992). The Plan's AD & D provision covers losses when an accident is the sole cause of the injury ... and that injury is the sole cause of the loss. Admin. R. at 40. To obtain benefit payment, claimants must notify MetLife and provide satisfactory proof of that loss. Id. at 43. Here, MetLife reasonably decided that Ms. Hancock failed to prove accidental death. MetLife's denials of Ms. Hancock's claim and appeals relied on Verla Hancock's death certificate and autopsy report. The autopsy found [n]o evidence of natural disease, injury or intoxication sufficient to explain death. Id. at 217. The report noted that Verla Hancock had a history of prescription-drug abuse and that findings at the scene of death were highly suggestive of death due to an overdose of Oxycontin; but it added that toxicologic testing reveals no evidence of excessive amounts of Oxycontin or other intoxicants. Id. It concluded that Verla Hancock died as a result of undetermined causes. Id. Ms. Hancock's theory is that her mother slipped in the bathroom and died when she hit her head on the toilet. According to her first appeal letter, Detective Johnson, who had investigated Verla Hancock's death, said that it looked like [Verla Hancock] slipped, fell, and hit her head, id. at 174, and Dr. Grey, the medical examiner, agreed that Ms. Hancock's theory was possible. On her second appeal Ms. Hancock submitted MRA's investigative report as additional evidence of accidental death. MRA found that Verla Hancock's bathroom floor would be slippery when wet. The report described other facts that strongly suggest that [Verla] Hancock had fallen down in the bathroom. Id. at 165. For example, in the six months before her death, Verla Hancock had fallen 12 times, including once approximately six days before her body was discovered, when she fell and hit her head on the clothes dryer. She had suffered from neuropathy resulting in foot drop, had problems with depth perception, and complained of dizzinessall of which increased the likelihood of a fall. And the position of her body and the overturned chair were consistent with a slip and fall. But the report also noted that she had had obstructive sleep apnea, which could have stopped her breathing once she became unconscious. Significantly, MRA did not affirmatively conclude that death had been accidental, only that a conclusion that [Verla] Hancock's death appears to be related to an accidental fall appears to be reasonable. Id. at 167. MetLife rejected Ms. Hancock's submissions as unsatisfactory evidence of accidental death. It acknowledged her conversations with Johnson and Dr. Grey. But, MetLife explained, speculation about possibilities [does] not establish that an accident caused the decedent's death. Id. at 169. It pointed out that regardless of what Dr. Grey had told Ms. Hancock, he did not amend his official conclusion as to the cause of death. Likewise, MetLife found MRA's report devoid of evidence of an underlying accident. The report, MetLife said, only hypothesizes that Verla Hancock probably slipped, without establishing what had actually happened. Based on the government's reports and Ms. Hancock's submissions, MetLife reasonably concluded that she had not proved that her mother's death was accidental. To be sure, circumstantial evidence indicates that accidental death is a possibility. But the autopsy failed to find sufficient evidence to establish any cause of death, be it accidental or otherwise. We think it significant that MetLife relied on the government's investigations and conclusions to deny Ms. Hancock's claim. Such reliance reduces potential bias arising from MetLife's conflict of interest and shows that its decision was grounded on a reasonable basis. We therefore cannot conclude that MetLife's denial of Ms. Hancock's AD & D claim was arbitrary or capricious.