Often, individuals in Chicago claiming accidental death or life insurance coverage from an insurer get their claim denied. They receive a notice stating the claimant has a right to appeal the decision before suing the insurer under ERISA § 502(a). The claimant’s debate then becomes whether or not to involve a lawyer. Too often claimants conclude they will handle the appeal on their own, and speak to a lawyer if they have to file a lawsuit, believing the lawyer can collect up all the evidence and hire experts in court. Unfortunately, it can be difficult to introduce new evidence in court, as some colleagues out West recently experienced.
In Dowdy v. Metropolitan Life Insurance Co., No. 15-3764, 2016 U.S. Dist. LEXIS 52423 (N.D. Cal. Apr. 18, 2016), Dowdy claimed dismemberment benefits under an ERISA governed accidental death and dismemberment insurance policy issued by MetLife. Dowdy was in a serious car accident that left him with numerous injuries, include a fractured ankle. Over the next several months, the fracture led to an infection that could not be controlled, and ultimately resulted in a partially amputated leg. Dowdy’s doctors wrote that Dowdy’s diabetes significantly contributed to the inability to control the infection and need for an amputation. MetLife denied the claim because the policy required the accident be the sole cause of the dismemberment, exclusive of any other cause, and also excluded any loss that was contributed to by an illness. In litigation, Dowdy attempted to introduce additional evidence, including declarations from Plaintiff and his wife about the auto accident, the medical treatment and amputation. They also sought to introduce an additional medical chart and the traffic collision report.
Though the case was governed by a de novo standard of review, the court declined to consider the additional evidence (but it also declined to consider additional evidence MetLife tried to introduce). The court reasoned there are limited circumstances in which the court may allow introduction of evidence outside the administrative record. Though this case satisfied several of those circumstances, including claims under an insurance contract, the court deemed the information unnecessary to make a determination on the merits, and kept the material out of the record. Ultimately, Dowdy lost his claim, and MetLife owed him nothing. Thankfully, Illinois federal courts may have a more liberal approach on this issue, but the result may have been the same. See Krolnik v. Prudential Ins. Co. of Am., 570 F.3d 841, 843 (7th Cir. 2009) (explaining de novo review is really the court’s independent decision on whether the claimant is entitled to benefits, and not a “review”).
If you have a pending claim or appeal for accidental death and dismemberment insurance, do not wait until a final denial. Talk to an accidental death and dismemberment insurance lawyer today and get all the right evidence before the insurer.