Symetra in 2017 had denied Yates' death-benefits claim under the plan, writing in a denial letter that Yates' husband's death by overdose "was caused by his 'intentional act of using [h]eroin,'" according to the Eighth Circuit panel's opinion. Symetra did award benefits to Yates for spousal life insurance, the opinion said.

In addressing the issue on appeal of whether Yates' husband's death should fall under the "intentionally self-inflicted injury" exclusion in benefit plan's "Employee Accidental Death and Dismemberment Insurance" policy, the panel noted that the "dispositive question is … whether that overdose 'injury' was 'intentionally self-inflicted,'" while quoting policy exclusion language.

In then ruling that the policy exclusion does not apply, panel Judges Jane Kelly, Bobby Shepherd and Steven Grasz, in an opinion penned by Kelly, said that a 2005 Eighth Circuit opinion in King v. Hartford Life & Accident Insurance Co., in which an ERISA plan-covered employee died in a motorcycle accident while having a blood-alcohol level over the legal limit, was "instructive."

In the King case, wrote Kelly, a plan administrator had a denied a beneficiary's claim "in part based on an exclusion to coverage for losses caused by an 'intentionally self-inflicted injury, suicide, or suicide attempt, whether sane or insane.'"

In the King decision, the Eighth Circuit had explained, noted Kelly while quoting the 2005 decision, that "the 'most natural reading' of the 'intentionally self inflicted injury' exclusion did not include 'injuries that were unintended by the [plan] participant, but which were contributed to by alcohol intoxication.'"

And Kelly wrote on behalf of the panel that "like consuming alcohol, using heroin is not itself an 'intentionally self inflicted injury'; for example, a person who uses heroin to get high would not necessarily be thought of as an 'injured' party," citing the King opinion.

Kelly soon added that "Symetra contends, for instance, that the exclusion applies to Yates's husband's death because he 'purposely' used heroin," and then she said that "just because the act of using an illegal substance is purposeful does not mean that an injury stemming from that act, including a fatal overdose, was too."

In further knocking down arguments by the insurance company, Kelly noted that "Symetra also maintains that Yates's husband, as a 'longtime drug user,' was surely aware of the risks of using heroin and that his 'generalized knowledge' of such risks is sufficient for his death to fall under the 'intentionally self-inflicted injury' exclusion."

But then Kelly said that "even if we assume Symetra's characterization of Yates's husband's drug use is accurate, the argument attempts to replace an exclusion that applies only to 'intentionally self-inflicted' injuries with one that also includes injuries resulting from reckless, or even negligent, conduct."

Also in the opinion, Kelly and the panel said that Yates' accidental death-benefits claim was not blocked by her failure to exhaust internal review procedures, given that her benefit plan itself did not set out internal review or appeal procedures.

"First, a review of our cases confirms that the requirement that a plan participant first exhaust her administrative remedies before bringing an ERISA suit has consistently been premised on such remedies being expressly prescribed in the participant's written plan documents," Kelly wrote.

The judge then added that the Eighth Circuit has "said that the exhaustion requirement bars a denial-of-benefits claim under ERISA if a plan participant 'fails to pursue and exhaust administrative remedies that are clearly required under a plan," quoting the 2020 decision in McKennan v. Meadowvale Dairy Emp. Benefit Plan.

Kelly also pointed out that the panel's "conclusion" on the issue "finds support" in the recent, 2020 Sixth Circuit case of Wallace v. Oakwood Healthcare, Inc. "that addressed the very exhaustion issue Symetra raises here."

In the Wallace  case, "the plan administrator maintained that it was not required to describe its claims and internal appeal procedures in the written plan documents because those procedures were detailed in a 'benefits denial letter,'" Kelly noted.

But in its ruling the Sixth Circuit "observed that 'one of ERISA's central goals is to enable beneficiaries to learn their rights and obligations at any time by examining their written plan documents," wrote Kelly while quoting the Wallace decision.

Kelly then added, while still quoting the Wallace opinion, that "[i]n keeping with th[at] intent" the court held that for a plan administrator "to avail itself" of a judicially created exhaustion requirement, "its underlying plan document[s] must—at minimum—detail its required internal appeal procedures."

She also noted that Eighth Circuit has "consistently recognized the primacy of written plan documents when resolving ERISA claims."

Joshua Bachrach, a partner at Wilson & Elser in Philadelphia, helped to represent Symetra in the appeal, according to docket information. He could not be reached for comment.

Glenn Kantor of Kantor & Kantor in California helped to represent Yates. He also couldn't be reached.