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Jones v. Metro. Life Ins. Co.

Jones v. Metro. Life Ins. Co.

United States Court of Appeals for the Sixth Circuit

August 13, 2004, Argued ; September 29, 2004, Decided ; September 29, 2004, Filed

No. 03-1375

Opinion

 [*656]   [***2]  KAREN NELSON MOORE, Circuit Judge. This action arose from Defendant-Appellee, Metropolitan Life Insurance Company ("MetLife")'s, denial of Plaintiff-Appellant, Dolores K. Jones ("Jones")'s, claim for benefits under a Personal Accident Insurance ("PAI") policy in an employee benefits plan ("Plan") provided by General Motors ("GM") and governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). Jones [**2]  appeals the district court's judgment granting MetLife's motion for judgment on the administrative record and denying Jones's dispositive motion. Jones first asserts on appeal that the district court should have evaluated under a modified-arbitrary-and-capricious standard the denial of PAI benefits to Jones because MetLife was operating under a conflict of interest, as it was both the insurer and an administrator of the Plan. Jones next asserts on appeal that the district court erred by accepting MetLife's definition of the term "accident," which requires a claimant to demonstrate "unusual activity" or an "external force or event." Jones argues that MetLife's definition is arbitrary and capricious, and that the district court should have applied the federal-common-law definition of accident promulgated by the First Circuit in Wickman v. Northwestern National  [***3]  Insurance Co., 908 F.2d 1077, 1088 (1st Cir.), cert. denied, 498 U.S. 1013, 112 L. Ed. 2d 586, 111 S. Ct. 581 (1990), which merely requires the claimant to demonstrate that the injury was neither subjectively expected nor objectively foreseeable.

For the following reasons, we REVERSE the district [**3]  court's judgment granting MetLife's motion for judgment on the administrative record and REMAND this case to the district court with instructions to remand this claim to MetLife for reconsideration of Jones's medical evidence in light of this opinion.

I. BACKGROUND

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385 F.3d 654 *; 2004 U.S. App. LEXIS 20494 **; 2004 FED App. 0330P (6th Cir.) ***; 33 Employee Benefits Cas. (BNA) 2319

DOLORES K. JONES, Plaintiff-Appellant, v. METROPOLITAN LIFE INSURANCE COMPANY, GENERAL MOTORS, and GENERAL MOTORS LIFE AND DISABILITY BENEFITS PROGRAM, Defendants-Appellees.

Prior History:  [**1]  Appeal from the United States District Court for the Eastern District of Michigan at Detroit. No. 02-70704. George C. Steeh, District Judge.

Disposition: REVERSED and REMANDED.

CORE TERMS

benefits, district court, accidental, parties, cases, arbitrary-and-capricious, insured, arbitrary and capricious, definition of the term, external force, administrative record, present evidence, unusual activity, knee injury, documents, squatting, knee, conflicting interest, permanent disability, motion for judgment, accident insurance, denial of benefits, federal common law, deferential, unexpected, asserts, bending, argues, causes

Administrative Law, Judicial Review, Administrative Record, General Overview, Pensions & Benefits Law, ERISA, Civil Litigation, Civil Procedure, Appeals, Standards of Review, De Novo Review, Handling of Claims, Scope of Review, Arbitrary & Capricious Review, De Novo Standard of Review, Conflict of Interest Analysis, Federal & State Interrelationships, Federal Common Law, Preliminary Considerations, Insurance Law, Life Insurance, Accidental Death, Sole Cause Requirements, Claim, Contract & Practice Issues, Premiums