District Court Affirms MetLife’s Denial of AD&D Benefits Finding Insured’s Post-Surgical Death From Unintentional Narcotic Overdose Was Not Covered Under The Policy

In Wicks v. Metropolitan Life Insurance Company, No. 4:21-CV-1275-O, 2023 WL 5216493 (N.D. Tex. Aug. 14, 2023), under a de novo standard of review, Texas Northern District Judge Reed O’Connor affirmed MetLife’s denial of accidental death benefits, concluding that Plaintiff had not carried her burden of establishing that she was entitled to benefits based on the terms of the insured’s life insurance plan.

Plaintiff was the sole beneficiary to a life insurance policy issued to decedent’s employer, and under which he was a participant. On June 24, 2021, Decedent, weighing nearly 300 pounds, underwent elective gastric sleeve surgery. Post surgery, the physician issued multiple orders for pain medications, including prescriptions for morphine, fentanyl and Dilaudid as part of routine recovery from anesthesia. That afternoon, Decedent was observed ambulating the hallway with assistance but complained of pain for which he received additional Dilaudid. He was next found in bed unresponsive and not breathing. He died two days later having never regained consciousness. The Death Certificate ruled the manner of death as “natural” and the immediate cause of death as “anoxic brain injury” as a result of “cardiac arrest” and “aspiration of gastric contents” with the underlying cause of “unintentional narcotic overdose.”

MetLife paid the basic life insurance benefits to Plaintiff as the named beneficiary. According to the policy, the accidental death and dismemberment coverage paid benefits for “an accidental injury that is the Direct and Sole Cause of a Covered Loss.” However, excluded from coverage was “any loss caused or contributed to by physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity.” MetLife denied Plaintiff’s accidental death claim stating that the death did not result directly and solely from an accidental injury, and it found no evidence of an accident independent of other causes. MetLife further stated that “[e]ven if an accident independent of other causes had occurred, which is not proven by the documents, the claim is excluded by the Illness/Treatment Exclusion.

On appeal, MetLife secured an independent toxicology report in which the specialist stated that he could not conclude with a reasonable degree of medical certainty that an administered drug overdose caused decedent’s death. The toxicologist noted “[t]he dose of Dilaudid administered was an appropriate and accepted dose for pain relief following surgery” and “the timing was not that which would be expected with opioid related death.” Furthermore, the toxicologist stated that the decedent was obese, and “in the absence of this condition and the surgery that was performed to correct it, the decedent 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.”

The Court agreed with MetLife and found that Plaintiff’s claimed accident was not the “Direct and Sole Cause” of the insured’s death. First, the court noted that death from post-surgical pain medication fell under the umbrella of “standard complications of standard medical treatment” for a disease, as outlined by the Fifth Circuit in Thomas v. AIG Life Ins. Co., 244 F.3d 368, 369–70 (5th Cir. 2001) (obesity treatment-related deaths stem from the preexisting infirmity of obesity rather than from an accident, provided there was proper medical treatment). Second, the Court found the uncontroverted record showed that Decedent received an appropriate dose of Dilaudid, and Plaintiff provided no competent expert testimony showing that the doctor inappropriately prescribed an excessive amount or that the nurses failed to follow the prescription. Having failed to satisfy her burden of proof, the Court affirmed MetLife’s denial of AD&D benefits.

As this case demonstrates, entitlement to ERISA AD&D benefits can be a difficult arena to navigate, both during the claims process, and potentially in litigation. If your claim for life insurance or AD&D proceeds has been denied, contact us for assistance.