Accidental Death & Dismemberment (AD&D) insurance pays the insured and his or her beneficiaries a set amount of money if the insured’s death or dismemberment is the direct result of an “accident.” In the event of a death caused by an accident or an accident that results in the insured losing his or her eyesight, speech, hearing, or a limb, AD&D will pay the insured or his or her beneficiaries a specified amount. The term “accident” has been given many different meanings in insurance policies and has been heavily litigated throughout history. Courts have encountered significant difficulty attempting to determine when an event is an “accident” for insurance law purposes. While the definition of the term “accident” will vary based upon the specific provisions contained in the policy at issue, the following recent court decisions demonstrate the issues that can complicate the determination of whether a death or insuring event is accidental.
In Prather v. Sun Life & Health Ins. Co., 843 F.3d 733 (7th Cir. 2016), a case decided under ERISA, the insurance policy at issue limited coverage to “bodily injuries that result directly from an accident independently of all other causes.” An insured tore his Achilles tendon while playing basketball, and underwent surgery to repair his tendon. Despite the otherwise successful surgery, the insured collapsed at work and died shortly thereafter due to a blood clot that broke loose from his injured leg and traveled to his lung causing cardiac arrest. Sun Life argued that the insured’s cardiac arrest and ensuing death were not entirely consequences of his accident causing his Achilles tendon to tear, but was a consequence of the surgery he underwent. The court was not persuaded by Sun Life’s argument, instead determining that Sun Life failed to make any plausible showing that the surgery, rather than the accident that necessitated the surgery, caused the insured’s death. Even though a beneficiary has the burden to prove a death was accidental, the court explained that a beneficiary is not required to disprove any possible alternative cause of death, even when a policy requires a death result from an accident “independently of all other causes,” as such a requirement would give the insurer carte blanche to reject coverage in a case in which an accident is a conceded cause of death.
In McDonald v. Onebeacon Am. Ins. Co., 2015 WL 11439080 (N.D. Ga. 2015), the insured, a truck driver, was found unresponsive in his truck shortly after an accident, and he died later that day. The truck driver was massively overweight and suffered from an enlarged heart and other coronary issues, and an examining doctor concluded that heart disease and resulting arrhythmia were the cause of his death. The policy insuring the truck driver defined an “accident” as “a sudden, unexpected, specific and abrupt event that occurs by chance at an identifiable time and place.” The court denied the insurer’s motion for summary judgment in part, finding that even though the truck driver’s heart condition was quite possibly the only cause of his death and his crash, his heart episode could fall within the policy’s broad definition of an accident. The court reasoned that the truck driver’s heart episode, occurring at the moment he crashed his vehicle, was a sudden and specific event that appears to have been unexpected and independent of all other causes.
In Wichita Fireman’s Relief Ass’n v. Kansas City Life Ins. Co., 609 Fed. Appx. 530 (10th Cir. 2015), the chordal structures in a fireman’s heart ruptured while he was fighting a condominium fire. After the fire, the fireman underwent surgery revealing a damaged mitral valve and the three torn chordal structures. The fireman died shortly after surgery. The policy at issue provided benefits for a loss resulting “directly and independently of all other causes from accidental bodily injury.” The policy also excluded coverage for a loss resulting from “bodily or mental illness or disease of any kind, or medical or surgical treatment of the illness or disease.” The Wichita Fireman’s Relief Association argued that the fireman’s death was brought on by extreme physical exertion during the fire, and the insurance company argued that the fireman’s death was instead the product of chronic mitral valve disease. The appellate court found there were issues of material fact as to whether the fireman’s heart injury, brought upon by extreme exertion in fighting the fire, constituted accidental bodily injury. The court found that the rupture of the chordal structures within the firefighter’s heart could be found by a jury to be unexpected and unforeseen, even though the strenuous conditions were within his line of duty.
Given the varied interpretations that can apply to provisions within insurance policies covering accidental deaths, and the considerable difficulty courts have encountered when trying to determine what is an accident” for insurance purposes, having an experienced attorney matters to the success of your accidental death claim. If your claim for health, life, short-term disability, long-term disability, or AD&D insurance has been denied, call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA insurance claims.
