Accidental Death Benefits

Accidental deaths would be common in Grand Prairie, Arlington, Fort Worth, Hurst, Euless, Bedford, Keller, Saginaw, Grapevine, and any other place in Texas. It is simply one of those things that is going to happen.
A lot of people have insurance policy’s that provide coverage in the event of an accidental death. These policies are known as “accidental death” policies. The United States District Court, Southern District of Texas, Houston Division, issued an opinion on June 29, 2011, in the case styled, Cheryl Likens v. Hartford Life and Accident Insurance Company. This case made a summary judgment ruling regarding an accidental death policy that people who have these types of policies should understand. Here is some background.
Wesley Vincent fell at his home in February 2008, and suffered injuries to his cervical spine. He died as a result of that injury four days later. The discharge summary from the hospital listed his cause of death as “anoxic brain injury secondary to cardiopulmonary arrest.”
Vincent had a group life insurance policy with Hartford through his employer which provided a benefit for “accidental” death. Likens was the listed beneficiary on the policy, and she sought payment of the benefits. Hartford denied the claim due to Vincent’s intoxication at the time of his injury. More specifically, Hartford relied upon provisions of the policy requiring that the injury must arise from an accident “independently of all other causes,” and that the policy excludes injuries “sustained as a result of being legally intoxicated from the use of alcohol. Likens then filed this lawsuit.
The policy provided for an accidental death and dismemberment benefit for an injury leading to death in the maximum amount of $300,000. An “injury” is defined as “bodily injury resulting from accident and independently of all other causes which occurs while [Vincent] is covered under the policy. The “Exclusions” section of the policy provides in relevant part as follows:
The policy does not cover any loss resulting from … 8. Injury sustained as a result of being legally intoxicated from the use of alcohol.
The evidence in the case showed that Vincent drank alcohol at a local bar and he arrived home at approximately 11:30 p.m. An EMS report contains the following description of events:
Family stated that Vincent went out drinking tonight and that he was brought home by the bartender around 11 or 11:30. Vincent’s wife states that he was very intoxicated and kept falling down, she states that she tried to help him, but he told her that he was fine and that he was going to sit out on the porch … her granddaughter came home and found Vincent between the bbq pit and the hedge … she moved him onto his back … realized that he was not breathing …
A hospital report confirms that plaintiff reported an initial fall by Vincent, and that she also reported that Vincent was unable to make it from the yard into the house. A sheriff’s report for that same incident states that it was Vincent’s daughter who later found him on the ground, but she was “not alarmed because this was a regular occurrence.” Vincent was transported to the hospital, and his serum blood alcohol content shortly after the incident was reported as being .328 mg/dl. He never regained consciousness, and his life support was removed. The cause of death was reported as “anoxic brain injury secondary to cardiopulmonary arrest.”
A Certificate of Death lists the “immediate cause” of his death as “complications following blunt trauma with fracture of cervical spine,” and the “manner of death” is listed as “accident.” Also listed under “significant conditions contributing to death but not resulting in the underlying cause” is “chronic ethanolism.”
In analyzing this case, the court discussed legal rules for deciding these types of cases. They pointed out that if an insurance policy is worded so that it can be given a definite meaning or certain legal meaning, then the policy is not ambiguous and is construed by the court as a matter of law. An ambiguity exists where a policy is susceptible to more than one meaning. If, and only if, a court finds an ambiguity in the contract provisions, particularly in exclusionary clauses, the court should construe the policy strictly against the insurance company. And, if the insured’s construction of an exclusionary provision is reasonable, it must be adopted, even when the insurer’s construction is more reasonable.
As this court correctly pointed out, under Texas law, an insured has the burden of establishing coverage under the terms of an insurance policy. If the insured proves coverage, then to avoid liability the insurer must prove that the loss is within an exclusion. If the insurer proves that an exclusion applies, the burden shifts back to the insured to show that an exception to the exclusion brings the claim back within coverage. Sounds like a game of chess doesn’t it?
In making its ruling, in favor of Hartford, the court stated, “In this case, no reasonable jury could find facts that would avoid the intoxication exclusion of the policy. The facts of this case clearly establish that Vincent’s intoxication on the night he fell in his front yard is the proximate cause of his death, and this prevents plaintiff from recovering under the policy. The policy does not cover any loss resulting from … injury sustained as a result of being legally intoxicated from the use of alcohol. Hartford’s evidence conclusively establishes that the injuries Vincent sustained … and which led to his death, were caused by his extreme intoxication.”
The attorneys for Likens argued about the wording of the death certificate and where the words were placed and other such similar arguments. Thought these arguments on behalf of Likens were commendable, they did not persuade the court.