In Hagen v. Aetna Insurance Company, the Fifth Circuit Court of Appeals affirmed the trial court's denial of accidental death benefits to a beneficiary. The policy was obtained through the deceased's employment, therefore it was governed by a federal law commonly known as ERISA.
The policy provided that benefits were payable if death "was a direct result of a bodily injury suffered in an accident.” However the policy also provided that death “must not be due to, or contributed by, an illness or disease of any kind including a reaction to a condition that manifests within the human body or a reaction to a drug or medication regardless of the reason [the insured] ha[s] consumed the drug or medication.”
The insured suffered a fall in his home, fracturing his hip. He died a few weeks after surgery. The autopsy report stated that the cause of death was “complications of blunt force trauma of lower extremity with intertrochanteric fracture of femur” and listed as contributory causes "COPD, chronic alcoholism, and hypertensive cardiovascular disease. Under manner of death, the report read: “Accident (Fell).”
Aetna denied payment. It stated in the denial letter, "death was caused or contributed to by a bodily infirmity, illness and disease, use of alcohol, use of intoxicants and medical or surgical treatment which are limitations excluded by the Policy.”
The Fifth Circuit noted that under ERISA, it was not enough for the beneficiary to show that the fall caused the insured's death. Instead, ERISA allows an insurer to deny payment if “some concrete evidence in the administrative record” supports its determination. Essentially, courts will support an insurance company's decision in ERISA cases, even if the totality of the evidence weighs against the insurance company's decision. This is despite the inherent conflict of interest, as the entity whose money will pay the claim is left great discretion to determine if payment is due.