Selina Anderson, a federal employee, fell in a parking lot and broke her leg. While undergoing surgery for the injury, she developed a blood clot that lodged in her lung, causing a pulmonary embolism. She died a few days later. Her daughter, Brittany Finney, filed a claim for accidental death benefits under her mother's Federal Employees' Group Life Insurance (FEGLI) policy. MetLife denied the claim, citing two reasons: first, that the death was not solely the result of the accident, and second, that Anderson's underlying chronic lung disease contributed to her death, triggering a policy exclusion. The district court granted summary judgment to MetLife, and Finney appealed to the Eleventh Circuit.
Circuit Judge Grant, writing for the court, began by clarifying the standard of review. Unlike ERISA cases which often utilize a complex six-step inquiry, the court held that FEGLI cases should be governed by the contract's terms, which mandate arbitrary and capricious review. The court defined this standard as asking whether the insurer's decision is 'reasonable and reasonably explained.' The court then analyzed the policy text. While the policy required death to be the 'direct result' of an accidental injury, the court noted that the policy also contained an exclusion stating benefits would not be paid if the death 'in any way results from, is caused by, or is contributed to by' a physical or mental illness. The court found that the evidence, including an autopsy report and a reviewing physician's opinion, established that Anderson's chronic lung disease and other comorbidities contributed to her death. The court rejected Finney's argument that the insurer's interpretation rendered the policy void, noting that the policy still covers deaths caused solely by accidents without contributing illness factors. The court also distinguished this case from a prior ERISA decision, Dixon, noting that the specific contractual language in this FEGLI policy was broader and more explicit regarding illness exclusions.
The decision reinforces that insurers may deny accidental death benefits if a pre-existing condition contributed to the death, even if an accident was the precipitating event. It establishes that FEGLI claims are subject to a deferential arbitrary and capricious standard rather than the more rigorous ERISA framework. The ruling leaves open the question of whether a de minimis connection between an illness and death would trigger the exclusion, but confirms that significant comorbidities like Anderson's lung disease are sufficient to bar coverage.