and Submitted November 15, 2017 San Francisco, California
from the United States District Court No. 3:15-cv-03764-JST
for the Northern District of California Jon S. Tigar,
District Judge, Presiding
L. Mosley (argued) and Douglas A. Applegate, Seiler Epstein
Ziegler & Applegate LLP, San Francisco, California; Glenn
R. Kantor, Kantor & Kantor LLP, Northridge, California;
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.
Retirement Income Security Act
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
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
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.
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.
panel remanded the case to the district court for further
SESSIONS, District Judge.
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
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.
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.
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. ...