In Wicks v. Metropolitan Life Insurance Company, No. 23-11247, 2024 WL 4212891 (5th Cir. Sept. 7, 2024), the Fifth Circuit Court of Appeals upheld Metropolitan Life Insurance Company’s denial of accidental death and dismemberment (AD&D) benefits, finding that the terms of the ERISA plan, the administrative record, and the applicable law supports the district court’s holding that Plaintiff-Appellant Fonda Wicks failed to carry her burden of proving that an “accidental injury” was the “direct and sole cause” of her husband’s death which followed gastric sleeve surgery.
Wicks is the widow of Jackie Wicks, a participant in an employee welfare benefit plan that provided life and AD&D insurance benefits insured by MetLife. Wicks filed suit against MetLife after it denied payment of AD&D benefits for Jackie’s death. At the time of Jackie’s death, he was sixty years old with a complicated history of morbid obesity and obstructive sleep apnea. He underwent gastric sleeve surgery, which was completed without complications. After the surgery, he was administered 50 micrograms of fentanyl at 11:02 a.m. and at 11:06 a.m., 4 milligrams of morphine at 11:20 a.m., and 1 milligram of Dilaudid at 12:30 p.m. Shortly thereafter, Wicks found him unresponsive in his hospital bed. Unfortunately, efforts to revive him were unsuccessful and he was pronounced dead two days later. The death certificate listed that the manner of death was “natural” and the immediate cause of death was “anoxic brain injury” resulting from “cardiac arrest” and “aspiration of gastric contents,” with the underlying cause listed as “unintentional narcotic overdose.”
MetLife denied payment of AD&D benefits because Jackie’s death was not the “direct and sole cause” of an accidental injury, independent of other causes. MetLife concluded that the death resulted from complications following surgery, which Jackie underwent to treat morbid obesity. And even if an accident independent of other causes had occurred, the AD&D plan excludes any covered losses which are caused or contributed to by physical illness or infirmity. Here, Jackie’s death stemmed from his morbid obesity, his choice to undergo treatment for this illness, and the admission of hydromorphone to treat the related pain from the surgery. MetLife relied on an independent medical expert, Dr. Michael Darracq, who reviewed the medical documentation and determined that he could not conclude with a reasonable degree of medical certainty that the death was solely due to an overdose of administered drugs. He also opined that an overdose did not take place because Jackie received an appropriate dose of medication and died in a timeframe that would not be reasonably anticipated from the administered drug alone. Had it not been for his morbid obesity, and the surgery to correct it, Jackie would not have received postoperative medications that may have contributed to his death. For these reasons, MetLife denied Wicks’ appeal.
The district court granted judgment in favor of MetLife following a de novo review of the administrative record. The district court concluded that the record shows that Jackie received an appropriate dosage of Dilaudid and received proper medical treatment. Thus, his death was caused by the preexisting infirmity of obesity. Because he died from obesity, his death is not an accidental injury independent of other causes. An unintentional narcotic overdose was not the direct and sole cause of death. Wicks appealed.
The Fifth Circuit agreed with the district court and rejected Wicks’ arguments that she is entitled to benefits under the exception to the drug exclusion because Jackie died from an unintentional drug overdose administered by a physician. The court explained that Wicks’ case does not turn on the drug exclusion’s exceptions because Jackie’s death was not covered under the terms of the plan and an exception to an exclusion alone cannot create coverage. Wicks has the burden of proving entitlement to benefits. She has not done so in this case.
Fifth Circuit precedent has held that the standard complications of standard medical treatment for obesity were the foreseeable result of treatment for the disease rather than a covered accident. The court found persuasive the reasoning in Thomas v. AIG Life Ins. Co., 244 F.3d 368 (5th Cir. 2001), where the decedent suffered from morbid obesity, had two stomach stapling surgeries, and then died from sepsis after the sutures ruptured following the second surgery. The Thomas court explained that the death was the foreseeable result of the treatment and accidental death benefits were not payable. The court also agreed with Dr. Darracq’s conclusion that Jackie received an appropriate dose of Dilaudid and thus received proper medical treatment. Because he received proper medical treatment, his death was caused by his obesity and not an accidental injury. The court rejected Wicks’ argument that when an insurer denies accidental death benefits due to obesity as violating the direct and sole cause clause, the death should be naturally flowing from obesity or closely related to obesity. Lastly, the court explained that the district court did not need to address the policy exclusions and the exceptions to the exclusions because an exclusion cannot create coverage that would not otherwise exist under a policy. Judgment affirmed.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
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