MetLife Reverses Denial of Accidental Death Benefits for Drowning Death Under Alcohol and Drug Exclusion on Administrative Appeal
Our client’s wife died after drowning in their backyard swimming pool. Her death certificate listed the manner of death as an accident, but both the medical records and death certificate described drowning as the cause of death, with intoxication by alcohol and certain substances also noted.
Our client had dependent accidental death insurance coverage through an employee benefit plan connected with his employment and governed by ERISA. MetLife insured the plan
MetLife denied the claim
In its denial letter, MetLife relied on policy language requiring that an accidental injury be the “Direct and Sole Cause” of the covered loss. MetLife also relied on language excluding losses caused or contributed to by certain voluntary actions, including the intake or use of drugs, medication, sedatives, or alcohol in combination with drugs, medication, or sedatives.
MetLife pointed to the death certificate’s statement that our client’s wife died from drowning due to acute intoxication with ethanol, cocaine, alprazolam, and clonazepam. Although the death certificate listed the manner of death as accidental, MetLife took the position that the plan language, not the manner-of-death box on the death certificate, controlled the claim decision.
Because MetLife concluded that her death was caused or contributed to by an illicit drug and alcohol in combination with drugs or medication, it denied the dependent accidental death benefits.
That denial left our client baffled
His wife had not died of an overdose. Nothing in the record showed that alcohol, medication, cocaine, or any combination of those substances was independently fatal. She died because she drowned. The tragic question was not whether the accident may have involved intoxication. The legal question was whether MetLife’s policy excluded benefits when the alleged excluded condition may have contributed to the accident, but the accident itself caused the death.
That distinction mattered
Insurance companies often try to treat these two questions as the same. They are not. In accidental death cases, the policy wording can be critical. Some policies are written to exclude deaths that occur while a person is intoxicated. Some are written to exclude accidents caused by intoxication. Others require the insurer to prove that the excluded condition caused or contributed to the covered loss itself.
But MetLife’s policy did not simply say that benefits were barred whenever a death occurred while alcohol or drugs were present. Its policy required analysis of whether the covered loss, death, was caused or contributed to by the excluded condition.
Our client came to us for help with the administrative appeal
By the time we were retained, MetLife had already denied the claim. Under ERISA, the federal law governing many employee benefit plans, the administrative appeal is often the most important stage of the case. It may be the claimant’s last full opportunity to place evidence, legal arguments, medical records, and case law into the claim file before litigation. If the appeal is not handled properly, a later lawsuit can be much harder. The deadline for appealing an accidental death insurance claim is 60 days from receipt of the denial letter. If that deadline is missed, the case is over, and cannot be taken to court.
We immediately notified MetLife that we represented our client and requested the claim file and sought an extension to allow a meaningful review and response. At the same time, we filed an administrative appeal challenging MetLife’s denial.
The appeal focused on the central weakness in MetLife’s position: MetLife had treated the presence of alcohol and drugs as if that automatically defeated coverage. But the law does not allow an insurer to simply point to toxicology results and stop there. When policy language requires causation, the insurer must have evidence supporting the causal connection required by the policy.
We argued that the cause of the loss was accidental drowning. The medical evidence did not show that alcohol or drugs caused death by overdose. The drowning caused the death. Even if MetLife believed intoxication somehow played a role in the events leading to the drowning, that did not automatically mean the exclusion applied to the covered loss.
We also pointed out important factual details. The reported alprazolam and clonazepam levels were within the therapeutic range, and our client’s wife had prescriptions for both. The reported cocaine level was very low. The femoral blood sample was not drawn until approximately 22 hours after death. And the drowning was unwitnessed, meaning any claim about exactly how or why she entered or remained in the water necessarily involved uncertainty.
That uncertainty matters in an ERISA accidental death claim. An insurer may be entitled to evaluate the record, but it cannot deny benefits based on unsupported assumptions. Suspicion is not proof. A toxicology report may be relevant, but it is not always enough to establish that a policy exclusion applies.
The appeal also explained the legal distinction between an excluded condition causing an accident and an excluded condition causing the death itself. Courts across the country have recognized that distinction in accidental death cases. For example, if a medical event causes a person to fall into water, and the person then drowns, the question may be whether the medical event caused the death or merely caused the accident that led to the death. Many courts have held that when drowning is the direct cause of death, an underlying condition that merely set the stage for the accident may be too remote to bar recovery, depending on the policy language.
We relied on that same principle here. The accidental drowning was not a minor detail. It was the event that caused the death. MetLife’s policy did not allow the company to deny benefits merely because it believed alcohol or drugs may have helped explain why the drowning occurred. The policy required more.
Our appeal also addressed intoxication-exclusion cases specifically. Courts have repeatedly rejected attempts by insurers to deny accidental death benefits based only on the presence of alcohol, medication, or drugs where the policy requires a causal connection. An insurer cannot merely cite a blood alcohol level, list the general effects of alcohol or drugs, and then assume causation. There must be evidence tying the intoxication to the loss in the way required by the policy.
That was missing here
There was no witness who saw what happened in the pool. There was no concrete evidence proving that alcohol, cocaine, or medication caused the drowning. There was no proof that the substances were fatal in themselves. There was only an accidental drowning and MetLife’s conclusion that the substances noted in the records were enough to bar the claim.
We argued that they were not
The appeal was direct. We told MetLife that the denial was unsupported, arbitrary, capricious, and contrary to applicable law. We also made clear that our client was prepared to file suit if MetLife did not reverse its decision. He had already suffered the horror of losing his wife. He should not have to relive that tragedy through unnecessary litigation when the policy and the law supported payment.
MetLife reconsidered
Ultimately, MetLife decided to reverse its denial and process the claim for payment.
This case illustrates a recurring problem in accidental death insurance claims. When alcohol, prescription medication, or drugs appear in a medical record, some insurers treat those facts as if they automatically defeat coverage. But policy language matters. Evidence matters. Causation matters.
A death certificate may mention intoxication. A toxicology report may list substances. But that does not end the inquiry. The insurer must apply the actual policy language to the actual facts. If the policy requires the insurer to prove that a substance caused or contributed to the loss, then the insurer must do more than speculate.
This case also shows why the administrative appeal stage in an ERISA claim is so important. Our client did not simply send a short letter asking MetLife to reconsider. We built the appeal around the policy language, the medical evidence, the toxicology details, and the case law governing accidental death claims. We placed the key arguments into the administrative record and explained why MetLife’s denial could not be squared with the facts or the law.
For other families, the case is a reminder not to assume that an insurance company’s denial is the final word.
We were honored to help our client obtain justice during an extraordinarily difficult time.
Results may vary. Every case is different, and no outcome can be guaranteed.
