Accidental Death Policy

Life Insurance Lawyers in Grand Prairie and those in Fort Worth, Dallas, and other places in the metroplex area, would want to be aware of this case.
The opinion was issued on July 19, 2012, by the United States 5th Circuit Court of Appeals. The style of the case is, Cheryl Likens v. Hartford Life and Accident Insurance Company. Here is some background.
After coming home drunk, Wesley Vincent was found face-down in front of his house by his wife, Cheryl Likens. He was taken to the hospital but eventually died. Likens tried to collect as the beneficiary of an accidental-death insurance policy, but the claim was denied under an alcohol exclusion, because Hartford Life and Accident Insurance Company (“Hartford”) determined that the injury resulted from being legally intoxicated from alcohol. The district court granted summary judgment for Hartford based on the alcohol exclusion. This Court affirmed the trial court.
Vincent was driven home by a bartender at 11:30 p.m. after a night of heavy drinking. Likens saw him falling down, but instead of entering the house with her, he stayed outside to smoke a cigarette. Kayla Hudson came to the house later and found Vincent unconscious at the foot of the front-porch stairs. She alerted Likens, who came outside to check on Vincent. When Likens did not feel a pulse, she called for emergency help. EMS and deputies took statements from Likens and Vincent’s granddaughter.
At the hospital, a differential diagnosis indicated Vincent had suffered a myocardial infarction, cardiac arrest, respiratory arrest, and vertebrae abnormality. A CT scan found a fracture at the C2-3 vertebrae left facet joints but no sign of dislocation. After Vincent had been unconscious for several days with no brain activity, his family withdrew life support. His treating physician reported the cause of death as “anoxic brain injury secondary to cardiopulmonary arrest.”
Likens later requested that the Houston Medical Examiner’s Office investigate into the cause of death. A medical examiner performed an external examination of Vincent’s body and prepared a Death Certificate. The examiner determined that the immediate cause of death was “complications following blunt trauma with fracture of cervical spine”; and listed “chronic ethanolism” under the title “other significant conditions contributing to death but not resulting in underlying cause.” The examiner concluded that death was an accident and the injury occurred because of a fall. Likens made a claim with Hartford for death benefits. The policy covers losses, such as death, resulting from an “Injury,” defined as
“bodily injury resulting directly from accident and independently of all other causes which occurs while the Covered Person is Covered on the Policy. Loss resulting from a) sickness or disease . . . or b) medical or surgical treatment of a sickness or disease, is not con- sidered as resulting from injury.
The policy also excludes coverage for “any loss resulting from . . . [i]njury sus- tained as a result of being legally intoxicated from the use of alcohol.”
Hartford denied the claim, citing the alcohol exemption. Likens administratively appealed, and Hartford upheld its determination in a letter indicating that Wesley’s death did not meet the policy’s definition of “Injury” and that Texas has a legal presumption of intoxication when the blood alcohol is at least 0.08.
Likens argued the term, “legally intoxicated” was ambiguous and thus, coverage should be provided.
The Court responded saying, the term’s meaning is plain. It followed by examining Texas law regarding the interpretation of policy language in insurance contracts. Citing another case, the Court said, “The plain meaning of ‘legal intoxication’ is that one is intoxicated according to the definition specified in the law of that jurisdiction. Thus, in this insurance contract, ‘legally intoxicated’ mandates we use the definition of ‘intoxication’ applicable across multiple areas of Texas law.
Texas defines ‘intoxication’ as (A) not having the normal use of mental or physical faculties by reason of the introduction of alcohol, a controlled substance, a drug, a dangerous drug, a combination of two or more of those substances, or any other substance into the body; or (B) having an alcohol concentration of 0.08 or more.
TEX. PENAL CODE ยง 49.01(2). This definition applies to both civil and criminal law. Although the state could set different levels for these divers categories, Texas has not done so. Because this definition is broadly used in criminal and civil contexts, this is the applicable definition of legal intoxication, regardless of the activity at issue.”
Discussing further, the Court said that the law does not criminalize intoxication; it determines what levels of intoxication are too severe, then prohibits certain activities (such as driving) when a person reaches those levels.
Likens’s argument that Vincent’s fall could have been caused by clumsiness does not create a genuine issue as to whether the alcohol exclusion applies.
Though the language of the exclusion determines its scope, Texas cases generally interpret alcohol exclusions to apply even where alcohol is not the sole cause of death. The exclusion says that the policy does not cover injuries “sustained as a result of being legally intoxicated from the use of alcohol.” That language is even softer than the “direct result” language that has be read to mean a proximate cause. Because the exact level is ambiguous, the Court can interpret the test to require proximate cause, thereby giving the beneficial reading to the insured.
The Court then reviewed the evidence presented above and other evidence that was as damaging and sustained the district court ruling in favor of Hartford.
This case has similarities to many cases wherein the benefits of an accidental death policy are denied due to intoxication. It is important to realize that an experienced Insurance Law Attorney can often times get recovery on these benefits. A determination by the insurance company should never be taken as final.