At McKennon Law, we frequently see insurers improperly deny claims under accidental death and dismemberment (AD&D) policies, especially when toxicology results or policy exclusions are involved. Fortunately, ERISA provides policyholders with powerful appeal rights when these denials are unfounded. In a recent success story, our firm secured full payment of a $680,000 AD&D benefit from Metropolitan Life Insurance Company (MetLife) after an initial denial—without having to file a lawsuit.
Background: Denial Based on Intoxication Exclusion
Our client filed a claim for AD&D benefits after the tragic death of a loved one who was covered under a group policy issued by MetLife. The cause of death was complications of multiple drug toxicity involving prescribed medications, including amphetamine and benzodiazepines. However, MetLife denied the claim based on the policy’s intoxication exclusion, alleging that the presence of cocaine in the decedent’s system excluded the claim from coverage.
This conclusion was not only legally wrong, but medically unsound. The presence of cocaine metabolites did not mean the drug caused the death. The denial failed to account for the full toxicology report and other relevant medical records.
Our Strategic ERISA Appeal
Understanding the complexity of the issues at hand, the client engaged McKennon Law to handle the ERISA appeal. Our attorneys immediately launched a comprehensive review of the record and retained a leading medical expert—a board-certified pathologist with over 50 years of experience. The expert reviewed the autopsy, toxicology, medical records, and police reports and issued an opinion to a reasonable degree of medical certainty: the death was substantially caused by prescribed medications, and the amounts of cocaine had no-to-little causal connection.
We then submitted an extensive appeal letter that included the expert report, relevant medical literature, and persuasive legal arguments supported by ERISA case law. We demonstrated that the exclusion MetLife relied on was inapplicable and that the medical evidence overwhelmingly supported coverage.
The Result: Full Payment of the $680,000 Claim with Interest
Faced with the thorough appeal and compelling evidence, MetLife reversed its position. It agreed with our analysis and paid the entire $680,000 claim, including interest, without requiring our client to litigate the matter in federal court. This victory not only spared the client the stress, delay, and cost of litigation—it vindicated their rightful claim under the policy.
Key Takeaways for Policyholders
This case highlights several important lessons for beneficiaries and policyholders under ERISA-governed AD&D insurance policies:
- Intoxication exclusions are not absolute: Insurers frequently misapply these exclusions. Medical causation matters, and trace substances do not always invalidate a claim. If California law applies, there is a statute that controls the language of these exclusions and insurers always ignore this.
- Appeals matter: A well-supported appeal supported by solid expert evidence under ERISA can result in a full reversal without litigation.
- Expert support is often essential: Independent medical opinions can make or break a claim, especially when cause of death is disputed.
- Experienced ERISA attorneys are key: Navigating the administrative appeal process requires deep knowledge of the law, policy language, and the insurance industry’s practices.
Conclusion
At McKennon Law, we are proud to fight on behalf of individuals and families who are wrongly denied benefits by insurers. This case is a testament to the power of a well-crafted ERISA appeal and the importance of hiring experienced insurance attorneys. If your accidental death or disability claim has been denied, contact us for a consultation—we may be able to achieve the same success for you.