Pension & Benefits News Medical event exclusion precludes accidental death benefits
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Thursday, November 21, 2019

Medical event exclusion precludes accidental death benefits

By Pension and Benefits Editorial Staff

The widow of an insured who experienced a medical event causing him to lose consciousness before he fell off a tractor and was run over by it was not eligible for the death benefit under her ERISA accidental death insurance policy, a federal court in Mississippi held. The policy provided benefits only for a death that directly resulted from an accident and that was not related to any other cause; it excluded benefits if disease, medical, or surgical treatment contributed to the accidental loss. Although the court declined to speculate exactly what medical event caused the insured to lose consciousness, it reasoned that a medical event of some sort contributed or related to the insured’s ultimate death. Therefore, the accidental death benefits were precluded.

The daughter of the decedent saw her father slumped over the steering wheel of the running tractor he was riding to cut the grass. When she attempted to raise him and spoke to him, he was unresponsive and fell from the tractor, which then moved forward, hitting her and running over him. According to the daughter’s statement, her father was blue and did not appear to be breathing when she raised him up on the tractor seat before he fell to the ground. No autopsy was performed, but the death certificate cited the cause of death as an “accident” and noted medical factors (diabetes, hypertension, and heart disease) as leading to the immediate cause of death. The widow (beneficiary) sought the $50,000 accidental death benefit under her ERISA policy, but the insurer denied the claim due to a policy exclusion for deaths in which a non-accidental medical event contributed to accidental loss.

Policy provisions. “Accidental bodily injury” was defined in the policy as “bodily injury that is the direct result of an accident and not related to any other cause.” The policy also contained the following exclusion:

“Your plan does not cover any accidental losses caused by, contributed to by, or resulting from disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders.”

Findings. The court noted that in Sekel v. Aetna Life Ins. Co., 704 F.2d 1335, 1337 (5th Cir. 1983), death benefits were denied “even though the accidental injury was the proximate or precipitating cause,” because disease or bodily injury was “a contributing factor or cause” of death. Like the case at bar, Sekel involved elements of both a natural and accidental death. According to the court, there was no serious dispute here that the deceased was experiencing a medical event based on a “commonsense interpretation” of the daughter’s statement—that the deceased was slumped over the wheel of his tractor and remained unresponsive despite her shaking him, trying to lift him, her son’s screaming, and after she herself had fallen from the tractor. An exact medical cause of death was not required for the insurer to reasonably conclude that a medical event contributed to the insured’s death.

Moreover, “but for” the daughter’s decision to climb onto the tractor to assist her father, he would not have fallen off or been run over by it. Thus, her decision to climb onto the tractor could not be separated, in a causation sense, from an apparent medical event that caused her to act. According to the court, a medical event must be regarded as “contributing” to or “related to” the insured’s ultimate death. And although the death certificate listed “accident” as the cause of death, it also listed medical factors as contributing to the death.

While the court noted that the decedent had diabetes (which required daily medication) and two steel heart valves, it refrained from speculating about the exact nature of the medical event that caused him to lose consciousness. However, it was not speculative to conclude that a medical event caused the decedent to fail to respond when he slumped unconscious at the wheel of a moving tractor and could not be revived. These are not symptoms of a healthy person, the court reasoned. Because it appeared to the court that the insured’s death was not “the direct result of an accident and not related to any other cause,” death benefits were precluded under the policy.

SOURCE: Parsons v. Unum Life Insurance Company of America, (N.D. Miss.), No. 3:18-CV-223-MPM-RP, October 16, 2019.

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