Eleventh Circuit Upholds MetLife Death Benefits Denial in Federal Worker Case

February 6, 2026 | JacobiJournal.com — The Eleventh Circuit Court of Appeals has affirmed MetLife’s denial of accidental death benefits to the family of a federal government employee, ruling that the insurer acted within its contractual discretion when it applied a policy exclusion tied to contributing medical conditions.

The decision reinforces how courts analyze insurer discretion under ERISA-governed benefit plans, particularly when underlying health conditions intersect with accidental injuries. It also highlights a recurring point of dispute in benefits litigation: whether a death is truly “accidental” when preexisting illnesses play a role.

What the Case Was About

The case arose after a federal employee suffered a serious fall while exiting a vehicle, resulting in a fractured leg and ankle. The employee died several days later. Her beneficiaries sought accidental death benefits under a MetLife-administered policy tied to her federal employment.

MetLife denied the claim, citing policy language excluding coverage when death results in part from underlying physical illnesses or medical conditions. According to the insurer, medical records showed that preexisting health issues materially contributed to the death, placing the claim outside the scope of covered accidental loss.

The beneficiaries challenged the denial, arguing that the fall was the primary cause of death and that MetLife improperly relied on exclusions to avoid payment.

How the Eleventh Circuit Analyzed the Denial

On appeal, the Eleventh Circuit applied the “arbitrary and capricious” standard, which governs many ERISA benefit disputes when plan documents grant discretionary authority to the insurer.

Under that standard, courts do not decide whether they would have reached the same conclusion as the insurer. Instead, they assess whether the decision was reasonable and supported by substantial evidence.

The appellate panel concluded that MetLife’s interpretation of the policy exclusion was consistent with the plan’s language and supported by medical documentation. The court emphasized that insurers are permitted to rely on exclusions where evidence shows that underlying medical conditions contributed to death, even if an accident initiated the chain of events.

Why Contributing Illness Exclusions Matter

Accidental death policies frequently contain exclusions for losses that are caused or contributed to by illness, a provision that often becomes central in contested claims. These exclusions are especially significant in cases involving older workers or individuals with documented medical histories.

Courts have repeatedly held that insurers may deny benefits where medical evidence demonstrates that an accident alone was not the sole cause of death. In this case, the Eleventh Circuit found no indication that MetLife selectively interpreted evidence or ignored relevant medical findings.

From a legal standpoint, the ruling underscores how policy drafting and medical causation analysis can determine the outcome of benefits disputes.

Broader Implications for Benefits Litigation

The decision adds to a growing body of appellate case law favoring insurers when discretionary authority is clearly defined and exercised consistently. For claimants, the ruling illustrates the uphill battle of overturning benefit denials under deferential review standards.

The case also raises ongoing concerns among employee advocates about transparency in claims handling and whether exclusion clauses are applied too broadly. While no fraud findings were alleged in this matter, disputes of this nature frequently prompt scrutiny of insurer decision-making processes, internal medical reviews, and claim evaluation methodologies.

Where Readers Can Review the Court’s Reasoning

Readers interested in federal appellate decisions involving insurance and ERISA disputes can review opinions directly through the U.S. Court of Appeals for the Eleventh Circuit.

Why This Decision Matters

This ruling serves as a cautionary example for employees and beneficiaries relying on accidental death coverage. Understanding policy exclusions—and how courts interpret them—is critical when evaluating potential claims or disputes.

For insurers, the decision reinforces the importance of thorough documentation and consistent application of policy terms to withstand judicial scrutiny.

FAQs: Accidental Death Benefit Denials Explained

What is an accidental death benefits denial?

An accidental death benefits denial occurs when an insurer determines that a death does not meet the policy’s definition of an accident or falls within an exclusion, such as a contributing illness or medical condition.

Why do insurers deny claims based on preexisting conditions?

Many insurance policies exclude coverage if an illness or medical condition contributes to a death. Insurers rely on medical records and expert reviews to assess causation and determine eligibility for death benefits.

How do courts review ERISA benefit denials?

Courts often apply an “arbitrary and capricious” standard, meaning that the insurer’s decision regarding death benefits will generally stand if it was reasonable and supported by evidence.

Can families challenge a death benefits denial?

Yes. Beneficiaries may pursue administrative appeals and federal litigation to contest a denial of death benefits, though success depends on the policy language, the evidence presented, and the standard of judicial review. Understanding the terms of the plan and the reasons for denial is critical when evaluating options for recovering death benefits.

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