Death by Self-Administered Dialysis is Excluded
Post 5173
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Clear & Unambiguous Exclusion Effective
Dana Kleinsteuber died while administering her own dialysis at home. MetLife now agrees that tragedy was an accident but refused to pay because of an exclusion for losses caused or contributed to by the treatment of a physical illness.
In Charles M. Kleinsteuber v. Metropolitan Life Insurance Company, CIVIL No. 23-3494 (JRT/DTS), United States District Court, D. Minnesota (August 19, 2025) the USDC was faced with the interpretation of an exclusion in an ERISA plan.
KEY FACTS:
Dana Kleinsteuber’s Death:
Dana Kleinsteuber, diagnosed with end-stage renal disease (ESRD), was self-administering dialysis at home when she suffered acute blood loss and died. The cause of death was listed as ESRD and natural causes.
Insurance Claims:
Charles Kleinsteuber, Dana’s husband, filed claims for both life insurance and accidental death and dismemberment (AD&D) insurance. MetLife approved the life insurance claim but denied the AD&D claim, stating that the death was not accidental and was caused by the treatment of ESRD.
Legal Action:
Charles Kleinsteuber filed an ERISA action to recover the AD&D benefit, arguing that Dana’s death was accidental.
LEGAL POINTS:
Policy Exclusion:
The AD&D policy excluded coverage for losses caused or contributed to by the treatment of a physical illness. MetLife argued that Dana’s death fell under this exclusion because it was related to her dialysis treatment.
Court’s Analysis:
The court applied the abuse of discretion standard to determine if MetLife’s interpretation of the policy exclusion was reasonable. The court considered several factors, including whether MetLife’s interpretation was consistent with the goals of the plan, whether it rendered any language in the plan meaningless, and whether it conflicted with ERISA’s substantive or procedural requirements.
To determine whether MetLife abused its discretion in denying the claim, the Court performed a two-step analysis, asking (1) whether the insurer’s interpretation of the Plan language is reasonable, and (2) whether application of that interpretation to the facts is supported by substantial evidence.
The Policy excludes coverage when “treatment” of a physical illness “contributed to” the insured’s “loss.” MetLife interprets that language to mean that a person who accidentally bleeds out from an open port during self-administered dialysis is excluded from coverage.
When determining reasonableness of an ERISA policy interpretation, courts will interpret consistently with the goals of the Plan. When an administrator has offered a reasonable interpretation, courts may not insert their own interpretation because under an abuse of discretion review, courts are not tasked with determining the best or preferable interpretation.
The primary goal of an AD&D plan is to provide an employees’ benefit and welfare plan for its members. When paired with life insurance the goal is to increase the amount of recovery over the face amount of the policy when death is from an accident.
MetLife adequately explained the specific reasons for the denial in its initial denial letter. In that letter, MetLife explained that the death was not accidental because Dana’s Death Certificate listed her death as resulting from ESRD and natural causes. It also stated that even if the death were an accident, the policy exclusion applied because the police report showed that Dana passed away from a medical emergency involving a dialysis machine.
MetLife, therefore, complied with the regulation requirements in issuing its initial denial.As long as there is substantial evidence to show that Dana’s dialysis treatment contributed to her death, MetLife did not abuse its discretion in denying Kleinsteuber’s claim.
CONCLUSION
The USDC found that MetLife did not abuse its discretion in determining that the dialysis treatment contributed to Dana’s death, which triggered a policy exclusion. Therefore, the Court denied Kleinsteuber’s Motion for Summary Judgment and granted MetLife’s Motion for Summary Judgment.
The court found that MetLife did not abuse its discretion in denying the AD&D claim, as there was substantial evidence that Dana’s dialysis treatment contributed to her death.
ZALMA OPINION
ERISA is a program created by federal law and is interpreted by federal courts. When there is a legitimate, clear and unambiguous requirement that the Accidental Death policy required that the death is accidental and the loss was not caused or contributed to by the treatment of a physical illness. Since dialysis is the treatment of an illness and contributed to the death the exclusion applied.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
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No Right to Subrogation Against Tenant
Post 5231
Not Fair to Require Tenant to Pay for Damage Insured by LandlordSee the video at https://lnkd.in/gFkrp_6M and at https://lnkd.in/gQdFQBWj and at https://zalma.com/blog plus more than 5200 posts.
See the video at and at
For Insurer to Subrogate Lease Must Require Tenant to Obtain Insurance for the Benefit of the Landlord
In AmGUARD Insurance Co. v. Tyrone Ellis and Shakyra Ellis, U.S. District Court, District of Connecticut Civil No. 3:25-cv-946 (JCH) (November 19, 2025), Judge, Janet C. Hall the defendant’s Motion to Dismiss the Amended Complaint on the basis of Connecticut’s anti-subrogation doctrine required dismissal.
KEY FACTS
Landlord Michael Caldwell, a Connecticut citizen, owned a multi-family building in Windsor, Connecticut. Defendants Tyrone and Shakyra Ellis were residential tenants in the building. On or about March 1, 2025, a fire ...
Debt Resulting from Fraud is Not Dischargeable in Bankruptcy
Post 5230
Read the full article at https://lnkd.in/gpF3y7Vd, see the video at https://lnkd.in/gR5cVcbY and at https://lnkd.in/gch6Q4_V, and at https://zalma.com/blog plus more than 5200 posts.
Knowing Misappropriation and Conversion of Funds is Fraud
In re Matthew Jene Tubbs (Bankr. N.D. Tex., Fort Worth Div., No. 22-42728-MXM-7; Adv. No. 23-04019-mxm), October 15, 2025 .
Key Facts
Plaintiffs (Robles) and Defendant (Tubbs) met through their church; both held leadership roles. In Feb 2021 Robles home suffered major water damage from Winter Storm Uri and insurance paid $173,000.
In the Fall of 2021: Tubbs represented to Mr. Robles that he personally built a newer house and large barn on his parents’ property “with his own hands” (except foundation/insulation). That he had 10 years’ experience overseeing window/door installations at a major home-improvement chain, was a licensed contractor (false) and carried general contractor liability insurance.
Relying on ...
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ZIFL-Volume 29 Number 22
THE SOURCE FOR THE INSURANCE FRAUD PROFESSIONAL
Post 5228
Zalma’s Insurance Fraud Letter (ZIFL) continues its 29th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at http://zalma.com/zalmas-insurance-fraud-letter-2/
Read the full 20 page issue of ZIFL at http://zalma.com/blog/wp-content/uploads/2025/11/ZIFL-11-15-2025-1.pdf
Man Bites Dog Story – Hertz Sues Alleged Fraudsters
Hertz Successfully Refuses to Pay Alleged Fraudulent Health Care Providers
Proactive Victim of Fraud Defeats Health Care Providers
More McClenny Moseley & Associates Issues
This is ZIFL’s thirty eighth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be ...
The Professional Claims Handler
Post 5219
Posted on October 31, 2025 by Barry Zalma
An Insurance claims professionals should be a person who:
Can read and understand the insurance policies issued by the insurer.
Understands the promises made by the policy.
Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
Are competent investigators.
Have empathy and recognize the difference between empathy and sympathy.
Understand medicine relating to traumatic injuries and are sufficiently versed in tort law to deal with lawyers as equals.
Understand how to repair damage to real and personal property and the value of the repairs or the property.
Understand how to negotiate a fair and reasonable settlement with the insured that is fair and reasonable to both the insured and the insurer.
How to Create Claims Professionals
To avoid fraudulent claims, claims of breach of contract, bad faith, punitive damages, unresolved losses, and to make a profit, insurers ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
