My client’s husband had a seizure and fell in his home. He struck his head on the floor which resulted in a traumatic brain injury. Tragically, he later died of the TBI.
At the time of his death, he was a plan participant in an ERISA benefits plan sponsored by his employer. One of his benefits was an Accidental Death and Dismemberment insurance policy issued by Metropolitan Life. His widow submitted the claim for Accidental Death and Dismemberment benefits.
The ERISA policy contained an exclusion for losses that are "caused by or contributed to" by a medical condition. Metlife denied the claim based on the medical condition exclusion.
I have filed an administrative appeal under ERISA. I believe that the exclusion only applies to deaths that are caused by a medical condition, not accidents that are caused by medical conditions. Case law from as far back as the 1800’s support our position on this appeal.