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Dowdy v. Metropolitan Life Insurance Co.

United States Court of Appeals, Ninth Circuit

May 16, 2018

Tommy Dowdy and Sharon Morris-dowdy, Plaintiffs-Appellants,
v.
Metropolitan Life Insurance Company, Defendant-Appellee.

          Argued and Submitted November 15, 2017 San Francisco, California

          Appeal from the United States District Court No. 3:15-cv-03764-JST for the Northern District of California Jon S. Tigar, District Judge, Presiding

          Mark L. Mosley (argued) and Douglas A. Applegate, Seiler Epstein Ziegler & Applegate LLP, San Francisco, California; Glenn R. Kantor, Kantor & Kantor LLP, Northridge, California; for Plaintiffs-Appellants.

          Rebecca Hull (argued) and Denise Trani-Morris, Gordon Rees Scully MansukhaniLLP, San Francisco, California; Ian S. Linker, Metropolitan Life Insurance Company, New York, New York; for Defendant-Appellee.

          Before: Marsha S. Berzon and Michelle T. Friedland, Circuit Judges, and William K. Sessions, [*] District Judge.

         SUMMARY [**]

         Employee Retirement Income Security Act

         The panel reversed the district court's judgment in favor of the defendant in an ERISA action challenging the denial of accidental dismemberment benefits under an employee welfare benefit plan.

         The plaintiff suffered a serious injury to his left leg as the result of an automobile accident, and his leg was eventually amputated below the knee. The defendant denied coverage because the plaintiff's injury was complicated by his diabetes.

         The panel held that the district court did not abuse its discretion in excluding evidence outside the administrative record, and any error on this issue was harmless because the external evidence did not support the plaintiff's claim.

         Under the ERISA plan, the plaintiff was entitled to coverage if his car accident was the "direct and sole cause" of the loss, and if amputation "was a direct result of the accidental injury, independent of other causes." The panel held that, even under the more demanding "substantial contribution" standard used when the applicable plan language is conspicuous, the plaintiff was entitled to recovery because the record did not support a finding that the preexisting condition of diabetes substantially contributed to his loss.

         The panel remanded the case to the district court for further proceedings.

          OPINION

          SESSIONS, District Judge.

         OVERVIEW

         In 2014, Appellant Tommy Dowdy suffered a serious injury to his left leg as the result of an automobile accident. His leg was eventually amputated below the knee. Mr. Dowdy and his wife, Sharon Morris-Dowdy, sought accidental dismemberment benefits under an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). Appellee Metropolitan Life Insurance Company ("MetLife") denied coverage because Mr. Dowdy's injury was complicated by his diabetes, and the district court affirmed the denial. For the reasons set forth below, we hold that the Dowdys are entitled to coverage because Mr. Dowdy's diabetes did not substantially cause or contribute to his injury. The judgment of the district court is therefore reversed and this case is remanded for further proceedings.

         FACTUAL BACKGROUND

         On the morning of September 13, 2014, Mr. Dowdy, age 60, was driving eastbound on California State Route 4 when he lost control of his car. The vehicle struck a metal sign post, rolled onto its right side, traveled down a dirt embankment and spun clockwise before coming to rest. The California Highway Patrol ("CHP") officer who arrived at the scene noted that Mr. Dowdy had suffered serious injuries, including a "semi-amputated left ankle" and chest abrasions. After a "prolonged" extraction from his vehicle, Mr. Dowdy was transported by helicopter to the John Muir Medical Center and treated in the Intensive Care Unit.

         Mr. Dowdy remained in the hospital until October 11, 2014, at which time he was discharged to a skilled nursing facility. When discharged, he was "nonweightbearing" due to his leg injury. The injury failed to improve, and approximately three months later Mr. Dowdy was transferred back to the hospital for treatment of persistent infection issues. On February 13, 2015, Dr. Christopher Coufal amputated Mr. Dowdy's left leg below the knee.

         Through Mr. Dowdy's wife's employment at Bank of the West, the Dowdys had purchased accidental death and dismemberment insurance from MetLife ("the AD&D Plan" or "Plan"). The Plan is governed by ERISA. ...


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