Eleventh Circuit Confirms That An Insurer’s Subjective Determination Is What Matters When Policy Language Requires Proof Of Loss That Is “Satisfactory To The Insurer”

In Fla. Tube Corp. v. MetLife Ins. Co. of Conn, No. 14-10824, 2015 U.S. App. LEXIS 4208 (11th Cir. Mar. 17, 2015) (unpublished), the Eleventh Circuit Court of Appeals considered whether a life insurer was obligated to pay benefits upon its receipt of circumstantial evidence of the insured’s death, despite the fact that the insurer found the evidence to be insufficient given the circumstances surrounding the alleged death. The key issue for determination was whether policy language requiring the insurer to pay benefits upon its receipt of “any other proof satisfactory to [the insurer]” vested it with the necessary measure of discretion to deny the claim.

Background

The insured allegedly died in a plane accident soon after taking off from an airport in the Dominican Republic. The insured was alleged to be the plane’s pilot and sole occupant, and neither the wreckage nor a body were ever found. There was evidence from the insured’s assistant that he took the insured to the airport, saw him board the plane, and heard the insured mention concerns about electrical or battery problems with the plane.

However, there was no evidence of anyone seeing the insured actually fly the plane away. A report from the National Transportation Safety Board merely repeated equivocal information released by authorities in the Dominican Republic, stating that the plane “presumably” collided with coastal waters, its unidentified pilot was “presumed” dead, and the plane was “presumed” destroyed.

The insurer also considered that: (1) the insured’s initial death certificate had a date of death that predated the date of the alleged flight, (2) Dominican Republic authorities nullified a second death certificate due to irregularities in its issuance, and (3) the policy’s benefits were an indispensable part of the insured’s proposed plan for reorganization in his personal bankruptcy proceedings that were pending at the time of the alleged death.

The Policy Language and The Beneficiaries’ Argument

The insurance policy defined “Due Proof of Death” as “a copy of a certified death certificate; a copy of a certified decree of a court of a competent jurisdiction as to the finding of death; a written statement by a medical doctor who attended the deceased; or any other proof satisfactory to us.” Since none of the documents specified in the definition were available, the policy’s beneficiaries argued that the available circumstantial evidence, when viewed under an objective standard, satisfied the “any other proof satisfactory to us” requirement. More specifically, the beneficiaries argued that the language had to be considered under an objective standard, pursuant to which the inquiry would center on whether a reasonable person would find the adduced evidence to be sufficient for a finding of death.

The Court’s Determination

The court rejected the beneficiaries’ argument, noting that the language “any other proof satisfactory to us”—i.e., MetLife—was unambiguous, and that its plain meaning afforded the insurer discretion to decide what it considered to be satisfactory. In this regard, the court drew from ERISA case law, where policies containing similar language are more common. The court did suggest that an insurer’s discretion is not unlimited, observing in a footnote that an insurer may be subject to an implied reasonableness threshold “when presented with evidence that would be almost universally satisfactory.” However, the court noted that the case “did not reach that threshold.”

The Florida Tube opinion is important because it confirms that policy language meant to protect insurers’ subjective claim-handling determinations can be enforced, even if seemingly one-sided, so long as it is found to be unambiguous.

The attorneys at Hernandez Lee Martinez have extensive experience handling insurance coverage disputes and other actions where issues of contract interpretation are paramount. Please contact us to find out how we can help you in your particular situation.

March 31, 2015 - Categories: Legal Developments