Yates v. Symetra Life Ins. Co.

Yates v. Symetra Life Ins. Co.

Opinion

KELLY, Circuit Judge.

After her husband died of a heroin overdose, Terri M. Yates sought accidental death benefits under an employer-sponsored benefit plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001-1461. The plan's insurer, Symetra Life Insurance Company, denied her claim, and Yates sued. The district court¹ granted summary judgment in Yates's favor. Symetra now appeals, arguing [*2]  that Yates's suit is barred by her failure to exhaust internal review procedures and that her husband's death otherwise falls under an exclusion to coverage. Having jurisdiction under 28 U.S.C. § 1291, we affirm.

At the time of her husband's death, Yates worked at Phelps County Bank and participated in the company's employee benefit plan (the Plan). Her husband was also covered under the Plan as a dependent. The Plan was issued and managed by Symetra and governed by ERISA. Its various benefits were summarized in an "Employee Benefits Insurance Certificate" issued to covered employees, and that Certificate included the policies and Plan language at issue in this case.²

Among the Plan's benefits was an "Employee Accidental Death and Dismemberment Insurance" policy, under which Symetra paid a "benefit amount" if a covered individual "suffer[ed]" certain losses, including a "[l]oss of life," due to "accidental bodily injury." ] A qualifying injury must have been "a sudden and unforeseen event, definite as to time and place." The policy also included seven exclusions to coverage, including one, as is relevant here, that excluded "any loss caused wholly or partly, directly or indirectly by . . . intentionally [*3]  self-inflicted injury, whi[le] sane."

On December 20, 2016, Yates's husband was found dead in his bedroom. The parties do not dispute that he died of a heroin overdose. Yates subsequently filed a claim with Symetra for spousal life insurance and accidental death benefits under the Plan. Symetra awarded the former benefits but denied the latter. The company explained in a June 27, 2017 denial letter (the Denial Letter) that "in view of the fact that" Yates's husband's death was caused by his "intentional act of using [h]eroin," Yates was not entitled to accidental death benefits because losses caused by an "intentionally self-inflicted injury" were excluded from coverage.

Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.