ERISA AD&D Denial Survives Exhaustion Challenge: Michigan Court Holds Plan Document, Not the SPD, Controls Claims Procedures

In Strong v. Metropolitan Life Insurance Co., No. 25-12693, 2026 WL 1971254 (E.D. Mich. July 8, 2026), United States District Judge F. Kay Behm resolved two preliminary matters in an ERISA action challenging the denial of benefits under two employer-sponsored Accidental Death and Dismemberment (AD&D) policies. The court denied Defendant Metropolitan Life Insurance Company’s motion to dismiss for failure to exhaust administrative remedies, denied Plaintiff’s request for discovery, and remanded the matter to the Plan Administrator so Plaintiff could pursue an administrative appeal.

What benefits did the ERISA plan cover, and why did MetLife deny the claim?

The decedent, an hourly Ford Motor Company employee, secured group benefits that included two AD&D policies governed by ERISA. After her death, Plaintiff submitted a claim as beneficiary. MetLife denied the claim under both policies, relying on a death certificate and autopsy report that identified the cause of death as diphenhydramine (Benadryl) toxicity. MetLife concluded that the decedent voluntarily ingested a lethal dose of Benadryl in excess of her prescription, triggering a policy exclusion barring coverage for loss resulting from the voluntary ingestion of medication other than as prescribed. Plaintiff contended that MetLife misread the toxicology data, confusing nanograms per milliliter with micrograms per milliliter, and that the reported blood level fell well below toxic and lethal ranges.

Must an ERISA plan’s claims procedures appear in the plan document itself?

Yes. MetLife argued that Plaintiff failed to follow the appeal procedure set out in the Summary Plan Description (SPD) and that this failure required dismissal. The court rejected that argument. Applying Wallace v. Oakwood Healthcare, Inc., 954 F.3d 879 (6th Cir. 2020), the court explained that a plan fiduciary seeking to enforce ERISA’s exhaustion requirement must have an underlying plan document that details its internal appeal procedures. Here, the appeal process on which MetLife relied appeared only in the SPD, not in the plan documents in the administrative record. The court further held, under CIGNA Corp. v. Amara, 563 U.S. 421 (2011), that statements in an SPD do not constitute the terms of the plan unless the plan expressly incorporates the SPD or provides that a single document functions as both. Finding none of those circumstances present, the court concluded that the SPD’s claims process did not govern Plaintiff’s claim.

Did the plan document contain a claims procedure the beneficiary satisfied?

Yes. The plan document set out its own procedure for filing AD&D claims, which Plaintiff appeared to have followed. On that basis, the court deemed Plaintiff’s administrative remedies exhausted and declined to dismiss the action.

Can an ERISA claimant obtain discovery to challenge the accuracy of the administrator’s medical conclusions?

No, not on these facts. The court reaffirmed that discovery is generally unavailable in an ERISA case, where review ordinarily is confined to the administrative record, with a narrow exception for evidence supporting a procedural challenge such as bias or lack of due process. Although Plaintiff noted MetLife’s inherent conflict of interest as both administrator and payor, the court found that Plaintiff’s actual discovery requests, depositions of the Administrator and the Macomb County Medical Examiner and expert testimony, aimed to show substantive error in reading the toxicology data rather than to support a procedural challenge tied to the conflict. Because Plaintiff did not connect the requested discovery to a procedural challenge, the court denied the request.

What happens next in the case?

The court remanded to the Plan Administrator for Plaintiff to pursue an administrative appeal. The court retained jurisdiction but stayed the case pending that appeal, directing the parties to file joint status reports every 90 days.