On February 10, 2017, the US District Court for the Eastern District of Kentucky granted an insurer's motion to dismiss a participant's complaint challenging the insurer's benefits denial involving an accidental death and dismemberment (AD&D) policy (Miles v. Fed. Ins. Co., 5:16-CV-15-KKC (E.D. Ky. Feb. 10, 2017)). The district court determined that the facts did not support the participant's claim that the benefits denial was based on the conclusion that a decedent's death was due solely to suicide.

The decedent in this case, a covered dependent under an AD&D policy that was part of an ERISA health plan, died of accidental suffocation related to what the district court described as "asphyxiation-inducing activities to derive pleasure." The AD&D policy included an exclusion for accidents directly or indirectly related to a covered individual's suicide, attempted suicide, or intentionally self-inflicted injury. The decedent's father, a plan participant and the plaintiff in the case, submitted a claim for death benefits under the AD&D policy. The policy's insurer denied the participant's claim, reasoning that the death was not an accident because it resulted from the decedent's voluntary placing of a cord around his neck. The insurer affirmed its initial denial on appeal and did not reply to a voluntary appeal filed by the participant that included a coroner's report indicating that the death was accidental.

The participant then sued the insurer in district court under ERISA for wrongful denial of benefits under the policy, arguing that the denial was based solely on the insurer's opinion that the death was an intentional suicide (see Practice Note, ERISA Litigation: Causes of Action and Remedies Under ERISA Section 502 for Benefit and Fiduciary Breach Claims). Among other arguments, the participant asserted that the insurer:

Granting the insurer's motion to dismiss, the district court concluded that it could not grant relief on the alleged improper benefits denial. The court noted that the policy's terms did not require:

The court also rejected the participant's argument that the insurer wrongfully rejected his claim by basing its decision exclusively on the mistaken belief that a coroner had told the insurer that the death was an intentional suicide. The court reasoned that factual contradictions undercut the plausibility of the benefits claim. Specifically, the administrative record included evidence that the denial was based on the policy's exclusion for intentional injuries (and therefore not based solely on the view that the death was a suicide).

Although the court concluded that the complaint's allegations were insufficient to suggest an improper benefits denial, it provided the participant additional time to file an amended complaint to attempt to state a plausible claim for relief.

When litigation calls into question a benefits denial involving a plan's exclusion for suicide or intentional self-inflicted injuries, the thoroughness of a plan's administrative decisionmaking may dictate the outcome. In this case, for example, a significant portion of the district court's decision cites directly from the insurer's benefit denial letters, which articulated the bases for the plan's decision to deny benefits. That reasoning was enough to win the day, though the participant in this case has been given another opportunity to restate his complaint.