United States District Court, D. Arizona
MEMORANDUM OF DECISION AND ORDER
STEPHEN M. McNAMEE, Senior District Judge.
Before the Court is Plaintiff Grant Creno's and Defendant Metropolitan Life Insurance Company's ("MetLife") cross-motions for summary judgment. (Docs. 28; 30.) The motions are fully briefed (Docs. 38; 42; 46.) For the reasons that follow, Plaintiff's motion is denied and Defendant's motion is granted.
The facts of this case are virtually undisputed. Plaintiff's brother, Glen Creno ("Glen"), participated in a Life Insurance and Accidental Death and Personal Loss Coverage Plan (the "Plan") issued by MetLife to Glen's employer. (Doc. 53 ¶ 1.) The Plan is subject to the Employee Retirement Income Security Act of 1974 ("ERISA") (Docs. 54 ¶ 4; 43) and vests with MetLife, the claims administrator or "fiduciary, " "discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan" (Doc. 53 ¶ 6). Glen named Plaintiff Grant Creno as the sole beneficiary of the Plan's death benefits. (Id.)
Glen was found dead face down in a pond in his yard just before midnight on February 19, 2011. (Docs. 54 ¶¶ 6-7; 53 ¶ 18.) On or about July 20, 2011, MetLife received Plaintiff's claim for benefits, along with a certified copy of Glen's death certificate. (Doc. 53 ¶¶ 8-9.) The death certificate states that the "immediate cause of death" was "drowning" and lists "seizure disorder" as an "other significant condition contributing to but not resulting in the underlying cause" of death. (Doc. 53-2 at 6 (capitalization omitted).)
On July 25, 2011, MetLife requested copies of the autopsy report, toxicology report, and police reports, which Plaintiff submitted on August 1, 2011. (Doc. 53 ¶¶ 11-13.) Glen's death was investigated by Phoenix Police Department Officers Todd Ruggeri, Kale Roberts, Ryan Moody, and Tyler Kipper. ( Id. ¶¶ 18, 23.) As part of the investigation, Officers Ruggeri and Roberts interviewed Cathryn Creno ("Cathryn"), who was Glen's live-in estranged wife. ( Id. ¶ 19.) Cathryn reported that she was in California for the day and that the house was dark when she got home; she discovered Glen's body when she turned on the back yard light. ( Id. ¶¶ 20, 23, 24.)
Cathryn explained that Glen had a medical condition which caused seizures. ( Id. ¶¶ 23-24.) Although it had been years since Glen experienced a seizure, Cathryn thought a recent illness may have triggered the seizure. ( Id. ¶ 26.) She also explained that when Glen had seizures, he would roam around the house in a daze destroying parts of the residence. ( Id. ¶ 25.) Cathryn reported that when she saw a broken mirror she thought Glen may have had a seizure and suspected a seizure was related to his death. ( Id. ¶ 20, 24.)
The condition of Glen's and Cathryn's home was chaotic. Officer Roberts observed "droplets of blood from the front entry area to... the access area where the pond is located." ( Id. ¶ 26.) Officer Moody noted a broken lamp in the master bedroom, blood on the wall next to the broken lamp, and blood in the walk-in closet. ( Id. ¶ 27.) Officer Moody also noted that a toilet seat had been ripped from the toilet, and that the seat's top portion was in the living room. ( Id. ¶ 28.) Officer Kipper found a dresser drawer had been pulled out and was laying upside down, that the handle of a door to the back yard had been broken off and placed in a bath tub, and that there were several drops of blood in the tub. ( Id. ¶ 29.) Officer Kipper further found that a dining room chair and a section of a couch were on their sides in the living room and that a eyeglasses lens was in the middle of the floor in the dining room. (Id.) Officer Ruggeri reported the cause of death as undetermined and explained the condition of the home supported two theories: that an unknown person or persons may have contributed to Glen's death; or that Glen's death was related to a seizure. ( Id. ¶ 22.)
The autopsy report authored by the medical examiner noted Glen had "multiple blunt force injuries" including a laceration on his forehead and a contusion below the left eyebrow, a fractured lower cervical vertebral column, abrasions on his back, and various contusions on his extremities. ( Id. ¶ 16.) The autopsy report also noted that Glen was reported to have "a history of postictal agitation and aggressive behavior that would explain the numerous blunt force injuries and disarray inside" his home. ( Id. ¶ 17.) Given "the known circumstances surrounding death, the available medical history, and the findings on postmortem examination, " the autopsy report concluded that Glen "died from drowning in a back yard water feature, with a contributory factor of seizure disorder." (Id.)
MetLife reviewed the investigative, autopsy, and toxicology reports and sent Plaintiff a letter on August 22, 2011, stating that MetLife would pay the life insurance benefits, but not the Accidental Death and Disability ("AD&D") benefits. ( Id. ¶¶ 30-31.) Citing the death certificate, Cathryn's statements to the police officers, the investigative report, and the autopsy report, MetLife denied Plaintiff's claim for AD&D benefits because Glen suffered a seizure that significantly contributed to his death. ( Id. ¶¶ 32-34.) The letter also gave Plaintiff notice of his right to appeal the denial within 60 days by submitting argument and/or evidence that denial was improper. ( Id. ¶ 35.)
Plaintiff timely appealed the denial in a October 13, 2011, letter that did not include any additional information and simply argued that MetLife has committed "bad faith" and vowed action "in a court of law." ( Id. ¶ 36.) MetLife reviewed and considered all the information submitted with the claim and issued a letter upholding its initial determination. ( Id. ¶ 37.) The letter reaffirmed that, based on the record, Glen's death was contributed to by seizure disorder. ( Id. ¶ 38.) The letter also apprised Plaintiff of his right to free copies of MetLife's records and to bring a civil action. ( Id. ¶ 39.)
Plaintiff retained an attorney who requested MetLife reconsider its determination. ( Id. ¶ 41.) In a January 31, 2012, letter to Plaintiff's counsel, MetLife reiterated that the Plan does not pay AD&D benefits for deaths that are "contributed to" by a "physical or mental illness or infirmity, " but that it would voluntarily permit Plaintiff another opportunity to prove that Glen's seizure disorder did not "contribute to" his death. ( Id. ¶¶ 43-44, 47-48.) As part of that voluntary review, MetLife received and began processing medical records concerning Glen's seizure disorder. ( Id. ¶ 45.) These records confirmed Glen had been ill the weekend before he died and uniformly supported the fact that Glen was prone to seizures and was being treated by a neurologist for an ongoing "seizure disorder." ( Id. ¶¶ 49-51.)
However, the voluntary review was cut short and MetLife's initial determination was rendered final on July 10, 2012, when Plaintiff filed suit against MetLife. ( Id. ¶ 46.) Plaintiff challenged MetLife's denial of AD&D benefits pursuant to ERISA's civil enforcement provision, 29 U.S.C. 1132(a)(1)(B) in Maricopa County Superior Court. (Doc. 1-1 at 3-5.) MetLife timely removed the action to this Court based on federal question jurisdiction under ERISA. (Doc. 1.)
THE AD&D POLICY
The Plan's AD&D policy states in relevant part:
If You or a Dependent sustain an accidental injury that is the Direct and Sole Cause of a Covered Loss described in the SCHEDULE OF BENEFITS, Proof of the accidental injury and Covered Loss must be sent to Us. When We receive such Proof We will review the claim and, if We approve it, will pay the insurance in effect on the date of the injury.
Direct and Sole Cause means that the Covered Loss occurs within 12 months of the date of the accidental injury and was a direct result of the accidental injury, independent of other causes.
EXCLUSIONS (See notice page for residents of Missouri)
We will not pay benefits under this section for any loss caused or contributed to by:
1. physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity;
2. infection, other than infection occurring in an external accidental wound;
3. suicide or attempted suicide;
4. intentionally self inflicted injury;
5. service in the armed forces of any country or international authority, except the United States National Guard;
6. any accident related to:
travel in an aircraft for the purpose of parachuting or otherwise exiting from such ...