Court denies ERISA accidental death claim
As part of my practice of handling life insurance and accidental death claims, I review court decisions discussing claims that are granted or denied. Recently I come across a case from the Eighth circuit court of appeals dealing with a case out of Missouri.
The insurance company had denied payout on an accidental death and dismemberment claim and the court of appeals upheld that denial. A woman fell down a flight of stairs and suffered severe hemorrhaging and died. Her family made a claim under the accidental death policy.
The first step in the analysis is that federal law applied. This was an ERISA policy that she had obtained through her employer. ERISA is a federal law that preempts state laws and governs governs the enforcement interpretation of policies such as this, that are obtained through a private employer. With ERISA the deck is somewhat stacked against the employee and their families, because the ERISA administrator is generally the insurance company.
The courts have determined that that they are supposed to give substantial deference to the decision made by the plan administrator. This generally works in unfairness because it's the administrator who'll be making the claim and they're also the same entity that the courts are supposed to defer. Their interest is in denying claims because that's more profitable and that that presents an uphill battle.
In this case it doesn't appear the court really felt it was a close call. The policy had an intoxication exclusion and it was not going to pay for claims where the death was contributed to by intoxication. In this case the court noted that the woman was three or four times the legal limit for alcohol in her system and the court did not have any problem finding that at minimum that her alcohol blood level contributed to the fall down the stairs.
It is very important that when you have an accidental death claim that you consult an attorney who is experienced in evaluating those claims and also experienced in evaluating whether or not federal or state law applies.