Duncan v. Minnesota Life Ins. Co., No. 20-3512, 2021 WL 494709 (6th Cir. Feb. 10, 2021) is a case that involves an accidental death policy governed by ERISA that excludes payment for deaths caused directly or indirectly by bodily infirmity, disease, or illness. The insured in this case, Paul McVay, died following a traumatic subdural hematoma sustained after he fell out of his wheelchair. At the time of his death, McVay was a patient at Hillspring Health Care because he was suffering from acute lymphocytic leukemia, weakness, instability, and bacteremia. He needed assistance with basic activities of daily living and used a wheelchair to get around because of his unsteady gait.
Minnesota Life Insurance Company paid McVay’s life insurance benefits but denied payment of accidental death benefits because it believed that McVay’s leukemia and weakness indirectly caused his death. Specifically, it found that McVay’s death was not the sole result of an accidental injury, independent of all other causes. Medical records showed that McVay had leukemia resulting in critically low platelet counts and he was receiving physical therapy for significant bilateral lower extremity weakness which made him high risk for falls.
A forensic pathologist conducted an autopsy and concluded that the cause of death is traumatic subdural hematoma, contributed to by leukemia. Another doctor who completed the supplementary medical certification stated that the immediate cause of death was a traumatic subdural hematoma, the manner of death was an “accident,” and leukemia is a significant condition contributing to death but not resulting in the underlying cause. Based on these facts, the court found that Minnesota Life did not abuse its discretion in denying the claim due to the policy’s exclusion.
The court considered and rejected Plaintiff-Appellant’s (the executor of McVay’s estate) three main arguments on appeal. First, Plaintiff argued that de novo review should apply because the policy’s requirement of “due proof” is insufficient to confer discretionary authority to Minnesota Life. The court found that Plaintiff waived this argument by not objecting to the magistrate judge’s order holding that Minnesota Life’s decision should be reviewed for arbitrariness and capriciousness. Plaintiff also waived the argument that the ERISA regulations require de novo review because it did not raise this argument before the magistrate judge.
Second, Plaintiff argued that Minnesota Life’s decision should be overturned because it was influenced by a conflict of interest. The court determined that the decision was supported by substantial evidence; was the product of a deliberate, principled reasoning process; and was not unduly influenced by a conflict of interest. Minnesota Life argued that the court should apply the test announced in Ann Arbor Trust Company v. Canada Life Assurance Company, which precludes recovery if the injury is caused directly or indirectly from a preexisting illness. 810 F.2d 591, 593 (6th Cir. 1987). Plaintiff urged the court to adopt the “substantial factor” test first applied by the Fourth Circuit Court of Appeals in Adkins v. Reliance Standard Life Insurance Company, 917 F.2d 794, 797 (4th Cir. 1990). The Sixth Circuit did not decide whether it should apply a “substantial factor test,” because even under this test, the decision was neither arbitrary nor capricious.
Third, Plaintiff argued that Minnesota Life’s claims process involved procedural irregularities and did not comply with ERISA. The court declined to decide whether Minnesota Life substantially complied with ERISA because remanding the case to the administrator would be a “useless formality.” To the extent that Minnesota Life committed ERISA violations, Plaintiff did not show how he was prejudiced by them.
The court affirmed the decision of the district court.
LEAVE YOUR MESSAGE
We know how to get your insurance claim paid. Call today at: