District Court Enforces AD&D Policy’s 365-Day Loss Requirement, Dismissing ERISA Denial-of-Benefits Claim

In Camardelle v. Metropolitan Life Insurance Company, No. CV 25-1382, 2025 WL 3687691 (E.D. La. Dec. 19, 2025), the Eastern District of Louisiana dismissed an ERISA denial-of-benefits lawsuit at the pleading stage after concluding that the plaintiff’s claimed loss was not covered under the plain terms of his Accidental Death and Dismemberment (“AD&D”) policy. Although the plaintiff alleged that an accident in 2019 ultimately caused permanent blindness in one eye in 2023, the court held that the policy unambiguously required the physical loss to occur within 365 days of the accident. Because more than four years separated the alleged accident and the loss of vision, the court ruled that the plaintiff could not state a cognizable claim for benefits under ERISA § 502(a)(1)(B) and granted MetLife’s motion to dismiss.

Relevant Facts

The plaintiff was employed by Entergy Louisiana, LLC, which offered its employees various welfare benefits governed by ERISA. Through Entergy, the plaintiff elected AD&D and supplemental AD&D coverage issued by Metropolitan Life Insurance Company (“MetLife”). According to the complaint, the policy provided for a 50% benefit in the event of loss of vision in one eye.

The plaintiff alleged that on September 4, 2019, he suffered an accident that caused a corneal scratch to his right eye. While the initial injury did not immediately result in blindness, the plaintiff claimed that complications eventually led to permanent loss of vision in that eye following a medical procedure on October 10, 2023. More than four years after the alleged accident, the plaintiff submitted a claim for AD&D benefits in November 2023. MetLife denied the claim in April 2024, and the plaintiff pursued an administrative appeal while also requesting plan-related documents. After continued disagreement over the denial, the plaintiff filed suit.

Procedural Posture

The complaint asserted two primary causes of action: (1) a denial-of-benefits claim under ERISA § 502(a)(1)(B), and (2) statutory claims under ERISA §§ 1024 and 1132(c)(1) based on alleged failures to provide documents. The plaintiff also sought attorneys’ fees and attempted to invoke Louisiana penalty statutes.

MetLife moved to dismiss under Federal Rule of Civil Procedure 12(b)(6), arguing that the plaintiff’s claims were barred by the policy’s contractual time limits and, more fundamentally, that the plaintiff had not suffered a covered loss under the policy’s express terms. The court granted the motion and dismissed all claims.

Court’s Analysis and Holding

Rule 12(b)(6) Standard

The court began by reiterating the familiar Rule 12(b)(6) standard, emphasizing that while factual allegations must be accepted as true at the pleading stage, a complaint must still state a plausible claim for relief. Conclusory allegations and legal conclusions unsupported by factual content are insufficient.

Contractual Limitations Period Under ERISA

The parties devoted substantial briefing to whether the plaintiff’s claims were time-barred under the policy’s contractual limitations provisions. The court acknowledged that ERISA § 502(a)(1)(B) does not contain an express statute of limitations and that, under Supreme Court precedent, parties may agree to reasonable contractual limitations periods. Citing Heimeshoff v. Hartford Life & Accident Insurance Co., the court noted that a three-year contractual limitations period for ERISA benefits claims is generally enforceable.

However, the court made clear that the case could not be resolved solely on limitations grounds. Even assuming the plaintiff timely submitted proof of loss after October 10, 2023, the dispositive question was whether the alleged loss fell within the scope of coverage in the first place.

Interpretation of the AD&D Policy

Turning to the policy language, the court applied federal common law principles governing ERISA plan interpretation. Under those principles, plan terms are construed according to their ordinary and generally accepted meaning, as would be understood by a person of average intelligence and experience.

The AD&D policy provided that benefits were payable only if the insured sustained certain physical losses caused by a covered accident and if the resulting death or physical loss occurred within 365 days of that accident. While MetLife denied the claim in part on the ground that no qualifying accident had occurred, the court found it unnecessary to review the administrator’s determination under any standard of review.

Instead, the court assumed arguendo that the September 2019 incident constituted a covered accident. Even under that assumption, the plaintiff could not satisfy the policy’s second, independent requirement—namely, that the physical loss occur within 365 days of the accident. The plaintiff’s own pleadings and briefing established that total loss of vision occurred on October 10, 2023, more than four years after the alleged accident. Because the timing of the loss fell far outside the policy’s 365-day window, the loss was not covered as a matter of law.

The court rejected the plaintiff’s argument that he could not have filed a claim earlier because blindness did not occur until 2023. While acknowledging the unfortunate nature of the circumstances, the court emphasized that ERISA § 502(a)(1)(B) places “particular importance” on enforcing plan terms as written. Courts may not rewrite plan provisions to extend coverage beyond what the policy clearly provides.

Practical Takeaway

Camardelle reinforces the strict enforcement of AD&D policy timing requirements under ERISA. Even where an injury allegedly evolves into a disabling condition years later, courts will look to the precise temporal linkage requirements in the policy. For practitioners, the case highlights the need to analyze not only contractual limitations periods but also coverage-defining provisions—such as accident-to-loss timing clauses—that can independently foreclose ERISA benefits claims at the pleading stage.