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Hypothermia Not “Direct and Sole” Cause of Death – W.D. Pa.

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  • Hypothermia Not “Direct and Sole” Cause of Death – W.D. Pa.

    Hypothermia Not “Direct and Sole” Cause of Death – W.D. Pa.

    Attached is a case out of the Western District of Pennsylvania, Verba v. Metropolitan Life Insurance Company. This case is before the court on cross-motions for summary judgment. This case involves a claim for ERISA governed accidental death and dismemberment benefits. Pursuant to the plan document, an accident must be the direct and sole cause of death, “independent of other causes.” The decedent’s death was determined to be accidental due to a combination of drug poisoning and hypothermia. Defendant denied plaintiffs’ claim asserting the loss was not independently caused by an accident as well as citing the plan’s drug and alcohol exclusion. Plaintiffs appealed. The court found that defendant did not abuse its discretion in denying the claim, in part, because plaintiffs had not shown that the hypothermia was the sole and direct cause of death.

    Plaintiffs primary argument against MetLife’s conclusion that the death was not a covered claim is their assertion that the amount of cocaine and alcohol reported by the toxicology results were insufficient alone or together to cause death. Plaintiffs rely on Dr. Shane’s letter in which he opines that the toxic effects of the reported amounts of cocaine and alcohol found in Andrew’s body could not have caused his death.

    As noted, MetLife reviewed Dr. Shane’s letter but upheld the denial of the claim based on its conclusion that Andrew’s cocaine and alcohol use impaired him to a level such that he unwisely remained in an environment where he died of hypothermia. MetLife’s conclusion is rational and is supported by the substantial evidence cited above. Dr. Shane’s contrary opinion as to the effect of drugs and alcohol on the cause of death does not render MetLife’s conclusion that combined cocaine and alcohol use caused or contributed to Andrew’s death unreasonable, or arbitrary or capricious.

    Moreover, Dr. Shane focused exclusively on whether the reported amounts of cocaine and alcohol were by themselves sufficient to cause death, whereas MetLife reviewed the evidence under the Plan’s language. Dr. Shane did not offer an opinion as to whether Andrew’s combined cocaine and alcohol could have in any way contributed to his death by hypothermia. Nor does he offer an opinion as to whether hypothermia was the direct and sole cause of death, such that the combined drug and alcohol in his body played no role in the death. Even if Dr. Shane’s conclusion that cocaine and alcohol use did not cause Andrew’s death is a potentially possible conclusion, such a conclusion would only mean that more than one conclusion can be drawn from the evidence. MetLife’s conclusion arrived at after a review of the evidence is a reasonable conclusion. When facts in the record could potentially permit multiple conclusions the Court defers to the insurance company as factfinder when its decision is reasonable. Malin v. Metro. Life Ins. Co., 845 F. Supp. 2d 606, 615 (D. Del. 2012).
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