Dolores K. Jones v. Metropolitan Life Insurance Company, General Motors

*The Honorable Algenon L. Marbley, United States District Judge for
the Southern District of Ohio, sitting by designation.
1
RECOMMENDED FOR FULL-TEXT PUBLICATION
Pursuant to Sixth Circuit Rule 206
ELECTRONIC CITATION: 2004 FED App. 0330P (6th Cir.)
File Name: 04a0330p.06
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
_________________
DOLORES K. JONES,
Plaintiff-Appellant,
v.
METROPOLITAN LIFE
INSURANCE COMPANY,
GENERAL MOTORS, and
GENERAL MOTORS LIFE AND
DISABILITY BENEFITS
PROGRAM,
Defendants-Appellees.
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No. 03-1375
Appeal from the United States District Court
for the Eastern District of Michigan at Detroit.
No. 02-70704—George C. Steeh, District Judge.
Argued: August 13, 2004
Decided and Filed: September 29, 2004
Before: MOORE and COLE, Circuit Judges; MARBLEY,
District Judge.*
2 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
_________________
COUNSEL
ARGUED: Barbara H. Goldman, SHELDON L. MILLER &
ASSOC., Southfield, Michigan, for Appellant. Mark D.
Filak, HARDY, LEWIS & PAGE, Birmingham, Michigan,
for Appellees. ON BRIEF: Barbara H. Goldman,
SHELDON L. MILLER & ASSOC., Southfield, Michigan,
for Appellant. Kay R. Butler, David M. Davis, HARDY,
LEWIS & PAGE, Birmingham, Michigan, for Appellees.
_________________
OPINION
_________________
KAREN NELSON MOORE, Circuit Judge. This action
arose from Defendant-Appellee, Metropolitan Life Insurance
Company (“MetLife”)’s, denial of Plaintiff-Appellant,
Dolores K. Jones (“Jones”)’s, claim for benefits under a
Personal Accident Insurance (“PAI”) policy in an employee
benefits plan (“Plan”) provided by General Motors (“GM”)
and governed by the Employee Retirement Income Security
Act of 1974 (“ERISA”). Jones appeals the district court’s
judgment granting MetLife’s motion for judgment on the
administrative record and denying Jones’s dispositive motion.
Jones first asserts on appeal that the district court should have
evaluated under a modified-arbitrary-and-capricious standard
the denial of PAI benefits to Jones because MetLife was
operating under a conflict of interest, as it was both the
insurer and an administrator of the Plan. Jones next asserts on
appeal that the district court erred by accepting MetLife’s
definition of the term “accident,” which requires a claimant to
demonstrate “unusual activity” or an “external force or
event.” Jones argues that MetLife’s definition is arbitrary and
capricious, and that the district court should have applied the
federal-common-law definition of accident promulgated by
the First Circuit in Wickman v. Northwestern National

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 3
Insurance Co., 908 F.2d 1077, 1088 (1st Cir.), cert. denied,
498 U.S. 1013 (1990), which merely requires the claimant to
demonstrate that the injury was neither subjectively expected
nor objectively foreseeable.
For the following reasons, we REVERSE the district
court’s judgment granting MetLife’s motion for judgment on
the administrative record and REMAND this case to the
district court with instructions to remand this claim to
MetLife for reconsideration of Jones’s medical evidence in
light of this opinion.
I. BACKGROUND
A. Relevant Plan Provisions
This action arose from MetLife’s denial of Jones’s claim
for PAI benefits under a Plan provided by GM and insured by
MetLife. The parties agree as to which provisions of the Plan
are relevant to this appeal. First, the parties agree that,
through the following provision, GM has expressly reserved
and delegated to MetLife discretionary authority to interpret
the Plan and to evaluate claims under the Plan:
(b) Administration and Amendment
(1) The Corporation, as the Program Administrator,
shall be responsible for the administration of
the Program. The Corporation reserves the
right to amend, modify, suspend or terminate
the Program in whole or in part, at any time by
action of its Board of Directors or other
committee or individual expressly authorized
by the Board to take such action. . . . The
Program Administrator expressly reserves the
right to construe, interpret and apply the terms
of this Program. In carrying out its
responsibilities under the Program, the Carrier
also shall have discretionary authority to
4 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
interpret the terms of the Program and to
determine eligibility for and entitlement to
Program benefits in accordance with the terms
of the Program. Any interpretation or
determination made by the Program
Administrator or the Carrier, pursuant to such
discretionary authority, shall be given full force
and effect, unless it can be shown that the
interpretation or determination was arbitrary
and capricious. The determination of the
Corporation or, in the event of an appeal, of the
Carrier, shall be final and binding on the
Corporation, the insurance company and the
Employee or the Employee’s designated
beneficiary.
Joint Appendix (“J.A.”) at 268 (GM Plan). The parties also
agree that the above-quoted provision requires that courts
give some deference to MetLife’s interpretation of the Plan
and evaluation of claims under the plan, and therefore, that
this court should evaluate MetLife’s denial of benefits under
some permutation of the arbitrary-and-capricious standard.
The parties disagree, however, over whether the denial of
benefits should be evaluated under a less deferential,
modified-arbitrary-and-capricious standard because MetLife
was operating under a conflict of interest, as it was both the
insurer and an administrator of the Plan.
Second, the parties agree that Jones’s claim for PAI
benefits must be determined under the following provision:
(i) Payment of Benefits
If, while insured for Personal Accident Insurance, an
Employee, Spouse or Dependent Child sustains
accidental bodily injuries, and within one year
thereafter shall have suffered loss of life or any other
loss set forth in subsection (e), as a direct result of
such bodily injuries independently of all other

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 5
causes, the Carrier shall pay the benefit specified for
all such Losses. . . .
. . .
Only one amount, the largest to which the
beneficiary is entitled, will be paid for all losses
suffered by one covered individual resulting from
one accident.
J.A. at 333 (GM Plan). The Summary Plan Description
provides:
If you become totally and permanently disabled as a
result of an accidental injury while you are an active
employee you will be paid the full benefit amount of any
personal accident insurance (PAI) you elected in monthly
installments of 2% of that amount less any amount paid
for losses previously sustained, provided you submit
evidence satisfactory to the insurance company. “Total
and permanent disability” under PAI means the total and
permanent inability, as caused by an accidental injury, to
engage in regular employment or occupation for
remuneration or profit, as based on medical evidence
satisfactory to the insurance company.
J.A. at 88 (GM Summ. Plan Description). The parties agree
that Jones’s claim for PAI benefits turns upon the definition
of the term “accident,” and that the term “accident” is not
defined in the Plan or the Summary Plan Description. The
parties disagree, however, over whether the definition
proffered by MetLife in the course of denying Jones’s claim
is arbitrary and capricious.
B. Factual Background
Jones worked as an industrial nurse for GM. On
February 22, 1999, Jones injured her knee at work. On
September 1, 2000, Jones submitted to MetLife a claim form
6 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
1In its letters, M etLife indicates that both of these events occurred in
1999.
requesting PAI benefits. On that form, Jones described the
circumstances leading to her knee injury as follows:
“BENDING DOWN AND SQUATTING TO GIVE FIRST
AID TO EMPLOYEE – FELT SHARP PAIN IN MY RIGHT
KNEE IMMEDIATELY AFTER I STOOD FROM
SQUATTING POSITION.” J.A. at 60 (claim form). Also on
that form, Jones indicated that she became disabled on June 1,
1999, and was certified unable to work on May 31, 2000.1
On December 5, 2000, MetLife wrote to Jones informing
her that her claim for PAI benefits had been denied because
Jones’s description of her knee injury “does not constitute an
accident for purposes of the payment of Total and Permanent
Disability Benefits under [Jones’s] Personal Accident
Insurance” and because Jones’s “physician has not indicated
that [Jones is] totally and permanently disabled due to [her]
injury.” J.A. at 65 (MetLife letter 12/5/2000). In its
December 5, 2000 letter, MetLife stated that it would “gladly
consider any additional information you wish to submit
supporting your claim. . . . The additional information will be
re-evaluated and Metropolitan Life will advise you of its
findings.” J.A. at 66 (MetLife letter 12/5/2000). On
December 19 and 26, 2000, Jones sent to MetLife additional
documentation supporting her claim, including a doctor’s
receipts that indicate her diagnosis was “tear knee medial
meniscus,” her Social Security award letter for disability
insurance, a claim form for PAI benefits that her treating
physician, Dr. Salamon, had completed in more detail, and a
statement from Jones’s physician. J.A. at 87 (Jones letter
12/26/2000).
On February 9, 2001, MetLife wrote to Jones again
informing her that her claim for PAI benefits had been denied
because “‘bending down and squatting’, is not sudden,
unexpected and unforeseen. Therefore, it does not constitute

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 7
2Based upon the administrative reco rd, it is not clear whether Jones
erroneously used the modifier “hypo” instead of “hyper” when describing
her knee injury. The medical dictionaries that we consulted did no t list a
definition for the term “hypo-extension.” Dorland ’s defines
“hyperextension” as “extreme or excessive extension of a limb or pa rt,”
defines “hypo” as “a p refix signifying beneath, und er, below normal, or
deficient,” and does not include a definition for the term “hypo-
extension.” Dorland’s Illustrated Medical Dictionary 881, 892 (30th ed.
2003); see also Ta ber’s Cyclopedic Medical Dictionary (19th ed. 2001).
In any event, it is not for us to determine in the first instance whether
Jones erro neously described her injury.
3Michigan Occup ational Safety and Health Administration.
an accident for purposes of the payment of Total and
Permanent Disability Benefits under you[r] Personal Accident
Insurance.” J.A. at 63 (MetLife letter 2/9/2001). In its
February 9, 2001 letter, MetLife informed Jones that she
could appeal this decision and could include in that appeal
“any additional information that [she] wish[ed] to be
considered.” J.A. at 64 (MetLife letter 2/9/2001).
On April 9, 2001, Jones wrote to MetLife appealing the
December 5, 2000 and February 9, 2001 denials of her claim
for PAI benefits. In her April 9, 2001 letter, Jones explained
that “while in the course of my employment, and in an
emergency first aid situation, that while I bent down to a
squatting position in order to administer first aid that I hypo
extended my knee causing a rip and tear to the medial
meniscus”2 and stated that Taber’s Cyclopedic Medical
Dictionary defines “accident injury” as “‘[o]ccuring suddenly,
un ex pe ct ed ly, inadvertently; under unforeseen
circumstances.’” J.A. at 67 (Jones letter 4/9/2001) (emphasis
added). Jones further stated in her April 9, 2001 letter that
she felt “that an unexpected tear in the medial meniscus
received during the course of performing [her] job clearly
constitutes an accident. . . . [and that] MIOSHA3 deems [her]
injury an accident.” J.A. at 67-68. In her April 9, 2001 letter,
Jones also requested that MetLife send her a copy of the PAI
8 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
policy and inform her of MetLife’s definitions of the terms
“accident” and “total and permanent disability” in order to
enable Jones to provide MetLife with appropriate
documentation of her injury.
On May 7, 2001, MetLife wrote to Jones denying her
appeal. In its May 7, 2001 letter, MetLife stated:
The [PAI] plan itself does not define the word “accident”
or “accidental,” but applicable federal law does. Under
applicable federal law, “accident” means an unforeseen
undesigned sudden or unexpected event of an unfortunate
character. However, injuries resulting from natural and
ordinary activities are not “accidental” when there are no
external forces or events to trigger the injuries. For
example, a knee injury from bending and/or squatting
does not constitute an accident.
In your case, there was no outside occurrence that caused
your injury. In the course of your employment as a
registered nurse, you bent down and squatted to give first
aid to an employee. Consequently, your knee injury was
natural and not accidental. (While MIOSHA may have
deemed your injury to be an accident, a determination by
MIOSHA is not binding on the Plan.)
. . .
. . . Since we have determined that your injury was not
accidental, there was no need to closely examine your
medical evidence.
J.A. at 69-70 (MetLife letter 5/7/2001).
C. Procedural Background
On February 22, 2002, Jones filed a complaint in the
district court seeking judicial review of MetLife’s denial of
her claim for PAI benefits. The parties each filed motions for
judgment. The district court granted MetLife’s motion for

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 9
judgment on the administrative record and denied Jones’s
dispositive motion. The district court had jurisdiction
pursuant to 29 U.S.C. § 1132(a)(1)(B) and (e), as Jones
sought to recover benefits allegedly due under the terms of an
ERISA plan. This court has jurisdiction pursuant to
28 U.S.C. § 1291, as Jones filed a timely notice of appeal.
II. ANALYSIS
A. Standard of Review
The parties agree that when there is no evidence of a
conflict of interest, both the district court and this court
review de novo an administrator’s denial of benefits pursuant
to an ERISA plan, unless the plan clearly grants to the
administrator discretion to construe the terms of the plan or to
make benefit determinations. Wilkins v. Baptist Healthcare
Sys., Inc., 150 F.3d 609, 613 (6th Cir. 1998) (citing Firestone
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). The
parties also agree that if a plan expressly grants to the
administrator such discretion, and there is no evidence of a
conflict of interest, both the district court and this court must
review the administrator’s denial of benefits under the highly
deferential arbitrary-and-capricious standard of review. Moos
v. Square D Co., 72 F.3d 39, 41 (6th Cir. 1995). Moreover,
the parties agree that when reviewing an administrator’s
denial of benefits pursuant to an ERISA plan, both the district
court and this court may typically review only evidence
contained in the administrative record. Wilkins, 150 F.3d at
619.
Jones first asserts on appeal that the district court erred by
reviewing under the arbitrary-and-capricious standard the
denial of her claim for PAI benefits, arguing that MetLife had
a conflict of interest due to its status as both the insurer and
an administrator of the Plan. In response, MetLife argues that
Jones has not preserved her argument that the district court
should have modified the arbitrary-and-capricious standard,
as Jones conceded in the district court that the arbitrary-and-
10 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
4Typically, parties may not determine by agreement our standard of
review. K & T Enters., Inc. v. Zurich Ins. Co., 97 F.3d 171, 175 (6th Cir.
1996). It this case, however, the level of deference accord ed to MetLife’s
denial of benefit turns upon a factual circumstance, i.e., whether or not
MetLife was operating under a conflict of interest, and parties may
concede the existence of facts. In this case , Jones’s concession in the
district court that MetLife’s denial of her claim for benefits should be
reviewed under the arbitrary-and-capricious standard and Jones’s failure
to assert that MetLife was operating under a conflict of interest are
tantamount to a concession of fact, and not to an agreement to waive the
appropriate standard of review.
capricious standard applies and failed to raise in the district
court MetLife’s alleged conflict of interest.
We conclude that Jones failed to preserve her argument that
the district court should have reviewed under a modified-
arbitrary-and-capricious standard MetLife’s denial her claim
for PAI benefits.4 Jones conceded below that the denial of
her claim for PAI benefits should be evaluated under the
arbitrary-and-capricious standard and did not assert below
that this standard should be modified due to MetLife’s alleged
conflict of interest. In her dispositive motion below, Jones
stated, “[Jones] concedes that the case at bar should be
reviewed under the arbitrary and capricious standard. . . .
When it is possible to offer a reasoned explanation, based on
the evidence, for a particular outcome, that outcome is not
arbitrary and capricious. . . . In other words, if the decision is
‘rational in light of the plan’s provisions’ it should be
upheld.” J.A. at 567 (Pl’s Dispositive Mot.) (internal
citations omitted). Additionally, in her response to MetLife’s
motion for judgment on the administrative record, Jones
stated, “[Jones] admits that under the GM Plan, discretionary
authority has been retained by [MetLife] and that the standard
of review is pursuant to an arbitrary and capricious standard.”
J.A. at 583 (Pl’s Resp.). Therefore, we will evaluate under
the deferential arbitrary-and-capricious standard of review
MetLife’s denial of Jones’s claim for PAI benefits.

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 11
It is true that, “[r]eview under [the arbitrary and capricious]
standard is extremely deferential and has been described as
the least demanding form of judicial review.” McDonald v.
Western-Southern Life Ins. Co., 347 F.3d 161, 172 (6th Cir.
2003). “Under this deferential ‘arbitrary and capricious’
standard, we will uphold a benefit determination if it is
‘rational in light of the plan’s provisions.’” Univ. Hosps. of
Cleveland v. Emerson Elec. Co., 202 F.3d 839, 846 (6th Cir.
2000) (quoting Yeager v. Reliance Standard Life Ins. Co.,
88 F.3d 376, 381 (6th Cir. 1996)). The arbitrary-and-
capricious standard, however, does not require us merely to
rubber stamp the administrator’s decision. McDonald, 347
F.3d at 172. Under the arbitrary-and-capricious standard,
both the district court and this court must exercise review
powers. Id.
B. Definition of Accident
Jones next argues on appeal that the district court erred by
concluding that MetLife’s definition of the term “accident” is
not arbitrary or capricious. Jones asserts that the district court
should have applied the federal-common-law definition of
accident promulgated by the First Circuit in Wickman, which
merely requires the claimant to demonstrate that the injury
was neither subjectively expected nor objectively foreseeable.
In response, MetLife argues that the district court properly
held that MetLife’s definition of the term “accident” is not
arbitrary or capricious. MetLife asserts that Wickman is
distinguishable, in that there the insured’s “injuries resulted
from an occurrence outside the usual course of events.”
Appellee’s Br. at 32. MetLife argues that several federal
cases decided under the arbitrary-and-capricious standard
have upheld administrators’ interpretation of “accident” as
requiring “unusual activity” or an “external force or event.”
At the outset, we note that because the Plan expressly
granted to MetLife authority to interpret the Plan, we must
give deference to MetLife’s interpretation of ambiguous and
general terms of the Plan. See Admin. Comm. of the Sea Ray
12 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
5W e recognize that in Un iversity H ospitals, we gave less deference
to the administrato r’s interpretation because the administrator was
operating under a conflict of interest. Univ. Hosps. of Cleveland v.
Emerson Elec. Co., 202 F.3d 839 , 846 -47 (6 th Cir. 2000 ). Nevertheless,
we conclude that under even the most deferential review, adding
eligibility requirements to a plan is arbitrary and cap ricious.
6For examples of this variety of case, see Cozzie v. M etro. Life Ins.
Co., 140 F.3d 1104, 1106, 110 9-10 (7th C ir. 199 8) (ho lding that insured’s
injury was foreseeable, and thus not accidental, within the m eaning of a
Employees’ Stock Ownership & Profit Sharing Plan v.
Robinson, 164 F.3d 981, 986 (6th Cir. 1999), cert. denied,
528 U.S. 1114 (2000); Moos, 72 F.3d at 42-43. Discretion to
interpret a plan, however, does not include the authority to
add eligibility requirements to the plan. See Univ. Hosps. of
Cleveland, 202 F.3d at 849-50.5 We conclude that MetLife
acted arbitrarily and capriciously when it interpreted the term
“accident” in a manner that adds requirements not found in
the Plan documents or supported by federal common law.
The Plan documents do not define the term “accident.”
Specifically, the Plan documents do not require that an
insured be engaged in “unusual activity” or meet with an
“external force or event” in order for her injury to be
considered an accident. MetLife could have expressly
included such a requirement. Indeed, many of the insurance
policies discussed in the cases cited by the parties did contain
such a requirement. Because the policy at issue in this case
did not include an “unusual activity” or “external force or
event” requirement, MetLife attempts to rely upon federal
common law to supply this requirement.
As evidenced by the cases cited in the parties’ briefs, the
definition of the term “accident” has been heavily litigated
throughout history. The cases cited by Jones are of two
varieties — (1) those in which the insured had engaged in
risky behavior and the question being reviewed was whether
the resulting injury was accidental;6 and (2) those in which an

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 13
policy that covered “injuries caused solely by an accident” and was
governed by ERISA, when insured died in car wreck that occurred when
insured was driving while intoxicated); Wickman v. Northwestern Nat’l
Ins. Co., 908 F.2d 107 7, 10 88-8 9 (1st Cir.), cert. denied, 498 U.S. 1013
(1990) (holding that insured’s injury was foreseeable, and thus not
accid ental, within the mea ning of a policy that defined accident as “an
unexpected, external, violent and sudden event” and was governed by
ERISA, when insured died after climbing outside of guardrail on an
overpass and jumping or falling to the ground forty to fifty feet below);
Nelson v. Sun Life Assurance Co. of Canada, 962 F. Supp. 1010, 1012-13
(W.D. Mich. 1997) (holding that insured’s injury was foreseeable, and
thus not caused solely by an accident independent of all other causes,
within the meaning of a po licy governed by ERISA, when insured died in
car wreck that occurred when insured was driving while intoxicated);
Walker v. Metro. Life Ins. Co., 24 F. Supp. 2d 77 5, 780-81 (E.D . Mich.
1997) (same ); Miller v. Auto-Alliance Int’l, Inc., 953 F. Supp. 172, 175-77
(E.D. Mich. 19 97) (same); Cates v. Metro. Life Ins. Co., 14 F. Supp. 2d
1024, 1027 (E .D. Tenn. 199 6) (same); Fowler v. Metro. Life Ins. Co., 938
F. Supp. 476, 48 0 (W .D. Tenn. 199 6) (same); Holsinger v. New England
Mu t. Life Ins. Co., 756 F. Supp. 1279 (E.D. Mich. 1991) (holding that
insured ’s injury was foreseeable, and thus not caused solely by an
accident independent of all other causes, within meaning of policy
governed by ERISA, when insured died from non-therapeutic, intentional
ingestion of codeine).
The parties mentioned, but did not cite, cases deciding whether
claimants could recover accidental death benefits when the insured died
during autoerotic asphyxiation. The Second, Ninth, and Fifth Circuits,
applying Wickm an, have allowed such claimants to recover, but in each
instance, the court reviewed the denial of benefits de novo beca use the
plan did no t give to the administrator discretion to interpret the policy or
to make bene fit determ inations. See Critchlow v. First UNUM Life Ins.
Co. of Am., —F.3d—, 2004 WL 1773550, at *12-13 (2d Cir. Aug. 9,
2004) (holding that insured’s death during autoerotic asphyxiation was
caused solely by an accident, not by suicide or intentionally self-inflicted
injury, within the m eaning of policy governed by ERISA); Padfield v.
AIG Life Ins. Co., 290 F.3d 1121, 1125, 1127-30 (9th Cir.), cert. denied,
537 U.S. 10 67 (200 2) (same); Todd v. AIG Life Ins. Co., 47 F.3d 1448,
1451-53, 1456 (5th Cir. 1995) (same). Similar reasoning was used by the
Eighth and Seventh Circuits in cases deciding whether claimants could
recover accidental death benefits when the insured died from a drug
overdose. See, e.g., She eha n v. G uardian Life Ins. Co., 372 F.3d 962 (8th
Cir. 2004) (giving less deference to the administrator due to a conflict of
interest and holding that insured’s death from acute morphine intoxication
was caused by an accident, where the evidence indicated that the insured
14 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
unintentionally ingested a fatal do se of morphine); Santaella v. Metro.
Life Ins. Co., 123 F.3d 456, 463-65 (7th Cir. 1997) (applying de novo
review beca use the p lan did not give to administrato r discre tion to
interpret the policy and holding that insured’s death from a prescription
overdose was caused by an accident where the evidence indicated that the
insured unintentionally ingested a fatal dose of codeine).
7For examples of this variety of case, see Metro. Cas. Ins. Co. of N.Y.
v. Fairchild, 220 S.W.2d 803, 804-06 (Ark. 1949) (hold ing that under
state law, insured’s fatal heart attack brought about by strain from thawing
ice valve on roof was caused by an accident even though act of leaning
over roof to thaw the valve was voluntary, and also holding that the injury
was caused by “external, violent and accidental means,” independent of
all other causes even though insured may have had a heart condition, so
long as thawing the valve was the proximate cause of the injury);
Carrothers v. Knigh ts of Columbus, 295 N.E.2d 307, 309-310 (Ill. App.
Ct. 1973) (holding that under Illinois law, insured’s fatal heart attack
brought about by assault was caused by an accident, not by intentional
injury inflicted by another, where assailant did not intend to inflict fatal
injury, and also holding that the injury was caused by an accident
independent of all other causes, even though insured had hardened
arteries, so long as the assault was the proximate cause of the injury); Am.
States Ins. Co. v. Morrow, 409 N.E.2d 1140, 1141-42 (Ind. Ct. App.
1980) (holding that under Indiana law, insured’s fatal heart attack brought
about by smoke inhalation was caused by “external, violent and accidental
means,” indep endent of all other causes, even though insured may have
had a heart condition, because jury found that smoke inhalation was the
proximate cause of the injury); Rankin v. United Commerc ial Travelers
of Am., 392 P.2d 894, 901-02 (Kan. 1964) (holding that under Kansas
law, insured’s fatal heart attack brought abo ut by heat and exertion in
fighting pasture fire was caused by “external, violent and accidental
means . . . indep endent of all other causes,” where there was no evidence
that insured previously suffered from physical impairment); Brown v.
Metro. Life Ins. Co., 327 S.W.2d 252, 255-56 (Mo. 1959) (holding under
Missouri law, insure d’s fatal co ronary occlusion b rought abo ut by assa ult
by another person was caused by “external, violent and accidental
means,” indep endent of all other causes, even though insured had a heart
condition, because jury found that the assault was the proximate cause of
the injury); Hu ghe s v. Pro viden t Mu t. Life Ins. C o. of P hilad elphia, 258
S.W .2d 290 , 291-94 (Mo. Ct. App. 1953) (holding under Missouri law,
event had triggered an injury and the question being reviewed
was whether a preexisting condition prevented the injury from
being considered accidental.7 In the cases cited by MetLife,

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 15
that insured ’s brain hemorrhage brought about by sneezing attack caused
by insured inhaling whiskers from his razor was caused “ind ependently
of all other causes . . . through external, violent and accide ntal means,”
even though insured may have had weakened bloo d vessel, because d eath
followed closely after sneezing attack and weakened blood vessel was not
a proximate cause of injury); N.Y. L ife Ins. Co. v. W ise, 251 P.2d 1058,
1061-62 (Okla. 1953) (holding that under state law, rup tured veins in
esophagus brought about by insured pushing a car up a hill were caused
by “external, violent and accidental means” because the ruptured veins
were an unforeseeable consequence, and also holding that the injury was
independent of other causes, even though insured had cirrhosis of the liver
which may have caused varicose veins in his esophagus, because the jury
found that pushing the car was the proximate cause of the injury); Home
Ben efit Ass’n of Paris v. Smith, 16 S.W.2d 357, 359 (Tex. Civ. App.
1929); (holding that under state law, ruptured blood vessel brought about
by hand cranking a Ford was caused by an accident because it was
unforeseeable, even though the cranking was intentional, and also holding
that death was an accident, even though insured may have had hardened
arteries, because the jury found that hand cranking was the proxim ate
cause of the injury); Stoffel v. Am. Family Life Ins. Co., 164 N.W.2d 484,
487-90 (W is. 196 9) (ho lding that under W isconsin law, rup tured aorta
brought about by insured lifting a tractor wheel was caused by an accident
because it was unforeseeable, even though lifting was intentional, and also
holding that death was independent of other causes, even though insured
had cystic medionecrosis, because the jury found that insured would have
suffered considerable injury absent his pre-existing condition).
8For exam ples of this variety of case, see Mers v. Ma rriott Int’l
Group Accidental Death & Dismemberment Plan, 144 F.3d 1014, 1021,
1024 (7th Cir.), cert. denied, 525 U.S. 947 (1998) (holding that insured’s
fatal heart attack was not caused solely by an accident within the meaning
of a policy governed by ERISA because there was evidence that insured
suffered from heart disease); Winchester v. Prudential Life Ins. Co. of
Am., 975 F.2d 147 9, 14 85-8 8 (10th Cir. 199 2) (ap plying U tah law to
interpret a plan governed by ERISA and holding that a fatal heart attack
suffered by insured was not a “bodily injury” where there was no external
violence, and also holding that the claim ant had not put forth evid ence to
the proximate cause of the injury was not obvious and the
requirement that the insured have been engaged in unusual
activity or that there have been some external force is
intended to ensure that the injury resulted from an accident,
rather than from natural causes.8 In most of the cases cited by
16 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
rebut presumptio n that insured suffered from heart disease necessary to
prove that the accidental bodily injury was “independent[] of all other
causes”); Riesterer v. Crown Life Ins. Co., 653 F.2d 268 , 268 -70 (6 th Cir.
1981) (holding that under Michigan and Oregon law, a fatal heart attack
suffered by insured fireman carrying hose inside burning building was not
“accidental bod ily injury . . . independent of all other causes,” where
insured was engaged in normal work activities and there was no external
force); Sangster v. Metro. Life Ins. Co., 54 F. Supp. 2d 708, 712 (E.D.
Mich. 1999) (holding that fatal heart attack suffered by insured
immediately following car wreck was not caused solely by an accident
within the meaning o f a plan governed by E RISA because insured’s heart
con dition was an interdependent cause of insured’s death); Kolowski v.
Metro. Life Ins. Co., 35 F. Supp. 2d 1059, 1062-63 (N.D. Ill. 1998)
(holding that under Illinois law, fatal hea rt attack suffered b y police
officer six days after a major drug bust during which officer moved three
hundred pounds of cannabis was brought about by natural causes, and not
by an accident independent of all other causes, because the drug bust was
part of the officer’s normal job functions and there was no unforseen
trauma or external force); Desroches v. Monumental Life Ins. Co., No. C
97-4593 VRW , 1998 WL 4 70473, at *3-4 (N.D. Cal. 1998) (holding that
under California law, fatal heart attack suffered by insured after choking
on her vomit was not caused by an accident independent of all other
causes because it was not the result of an unforeseen e vent, but rather a
foreseeable consequence of insured’s pre-existing illness); Howard v.
Nat’l Educ. Ass’n of N.Y., 984 F. Supp. 103, 108-09 (N.D.N.Y. 1997)
(holding that fatal heart attack suffered by insured who was under a great
deal of stress from work was not an accidental injury within the meaning
of a plan governed by ERISA because there was no unforseen trauma or
external force); Haley v. Am . Int’l Life Assurance Co. of N.Y., 789 F.
Supp. 260 , 263-64 (N.D . Ill. 1992) (same).
MetLife, the insured died from a heart attack. Many of these
cases hold that there is a presumption that a heart attack is
caused by natural causes, which may be rebutted by evidence
of unusual activity, unforeseen trauma, or external force.
MetLife cites no cases, nor could we find any, suggesting that
there is a presumption that a knee injury or similar ailment is
caused by natural causes. When there is no presumption that
an injury resulted from natural causes, federal common law
does not require proof aimed at rebutting such a presumption.
Contrary to MetLife’s assertion, federal common law —
from pre-Erie diversity cases to present day ERISA cases —

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 17
9Com pare United States Mut. Acc. Ass’n v. Barry, 131 U.S. 100, 101,
121-22 (1889) (holding that insured’s death brought about by injury
caused by mishap during intentional jump from platform to ground below
was accidental within the meaning of a policy that covered death from
bod ily injuries caused by “external, violent, and accidental means”);
Aetna Life Ins. Co. v. Kent, 73 F.2d 6 85, 6 85-8 7 (6th Cir. 1934) (holding
insured ’s death from intentionally pulling trigger of gun pointed at his
head that he mistakenly thought was unloaded was accidental within the
meaning of a po licy that covered death from bodily injuries caused by
“accidental means”); Md. Cas. Co. v. Massey, 38 F.2d 7 24, 7 25-2 7 (6th
Cir.), cert. denied, 282 U.S. 853 (1930) (holding that insured’s death
brought about by infection resulting from wound caused by mishap when
insured intentionally plucked hair was accidental within the meaning of
a policy that covered “death effected through accidental means”), with
Landress v. Phoenix Mut. Life Ins. Co., 291 U.S. 491 , 495 -97 (1934)
(holding that insured’s death brought about by sunstroke was not
accidental within the meaning of a policy that covered death caused by
“external, violent and accidental means” because insured intentionally
exposed himself to sun and there was no unforeseeable intervening force
caused insured ’s death); Nickma n v. N.Y. Life Ins. Co., 39 F.2d 763, 764-
65 (6th C ir.), cert. denied, 282 U.S. 855 (1930) (same ); Pope v.
Prudential Ins. Co. of Am., 29 F.2d 185, 185-86 (6th Cir. 1928) (holding
that insured’s death brought about by hemorrhage during operation was
not accidental within the meaning of a policy that covered death from
“bodily injuries effected solely through external violence and accidental
causes” because insured intentionally underwent operation, it was not
uncommon for patients to hemorrhage during same operation, and there
was no evidence of a mishap during insured’s operation).
By citing cases that ap ply the accidental means versus accidental
results distinction we do not intend to revive what may be a defunct
distinction. Moreo ver, the P lan language does not indicate that it is an
accidental means policy, but M etLife’s denial of benefit letters indicate
that it believes the plan contains some fo rm of “accide ntal means”
requirement. We note that although the P lan indicates that it will pay “for
all losses suffered by one covered individual resulting from o ne accident”
J.A. at 333 (GM Plan), the Plan and the Summary Plan Description state
that PAI benefits are award ed for “accid ental bodily injuries.” J.A. at 333
(GM Plan); J.A. at 88 (GM Summ. Plan Description). We cite cases
focuses upon the expectations and intentions of the insured.
Some of these cases adhere to the accidental means versus
accidental results distinction, but hold that an injury caused
by an unintended and unexpected mishap during the course of
an intentional activity is caused by accident.9 Other cases
18 Jones v. Metropolitan Life Ins. Co. et al. No. 03-1375
following the accidental means versus accidental results distinction
because while there may be several definitions of the term “accident” that
find support in federal law, the definition proffered by MetLife finds no
such suppo rt.
reject the accidental means versus accidental results
distinction and hold that an injury is accidental if it is neither
subjectively expected nor objectively foreseeable. Critchlow
v. First UNUM Life Ins. Co. of Am., —F.3d—, 2004 WL
1773550, at *12-13 (2d Cir. Aug. 9, 2004); Padfield v. AIG
Life Ins. Co., 290 F.3d 1121, 1125, 1127-30 (9th Cir.), cert.
denied, 537 U.S. 1067 (2002); Cozzie v. Metro. Life Ins. Co.,
140 F.3d 1104, 1109-110 (7th Cir. 1998); Santaella v. Metro.
Life Ins. Co., 123 F.3d 456, 463-65 (7th Cir. 1997); Todd v.
AIG Life Ins. Co., 47 F.3d 1448, 1456 (5th Cir. 1995);
Wickman, 908 F.2d at 1088-89. Jones presented to the
administrator evidence that may pass either test. Jones
presented evidence that during the course of her bending
down to assist a patient, she “hypo” extended her knee.
Because Jones presented evidence that her injury was caused
by an unintended and unexpected mishap, she has presented
evidence that her injury was caused by an accident.
Additionally, Jones presented evidence that she did not
subjectively expect to injure her knee while bending down to
assist a patient during her normal work activities and that this
expectation was objectively reasonable. Because Jones
presented evidence that her knee injury was neither
subjectively expected nor objectively foreseeable, Jones has
presented evidence that she suffered an accidental injury.
In this case, MetLife added an eligibility requirement under
the guise of interpreting the term “accident” that does not
exist in either the Plan documents or federal common law;
therefore, MetLife’s interpretation of the Plan is arbitrary and
capricious. When denying Jones’s claim for PAI benefits,
MetLife applied an arbitrary-and-capricious definition of the
term “accident.” Moreover, in its May 7, 2001 denial of
Jones’s request for administrative review, MetLife indicated

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No. 03-1375 Jones v. Metropolitan Life Ins. Co. et al. 19
that it had not determined whether Jones was totally and
permanently disabled. Because application of the correct
definition of accident and the ultimate resolution of Jones’s
claim requires additional findings of fact, we will remand this
case to MetLife. Compare Univ. Hosps., 202 F.3d at 852,
with Williams v. Int’l Paper Co., 227 F.3d 706, 715-16 (6th
Cir. 2000).
III. CONCLUSION
For the foregoing reasons, we REVERSE the district
court’s order granting MetLife’s motion for judgment on the
administrative record and REMAND this case to the district
court with instructions to remand this claim to MetLife for
reconsideration of Jones’s medical evidence in light of this
opinion.

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