Accidental Death Claims Denial

Life insurance claims attorneys are needed any time an insurance company denies a claim.  Some cases the attorney will help the client make a recovery and other cases, at least the client had the claim investigated.

The Northern District of Texas, Dallas Division, issued an opinion in July 2021, dealing with a claim for accidental death life insurance benefits.  The styled of the case is, Damon Stewart, et al v. Mutual of Omaha Insurance Company.  The facts of the case are tough.

The insured had an accidental death policy with Mutual of Omaha.  The insured is alleged to have died after suffering a fall and hitting his head that caused his death.  A claim for benefits was denied and this lawsuit was filed.  Mutual of Omaha filed a motion for summary judgment based on the records they obtained in their investigation and there being no reliable evidence to the contrary.

The evidence in the case is as follows:

Mutual of Omaha obtained a police “Incident Report,” a medical investigator report,an emergency response report completed by emergency response personnel, and a physician review.  Neither the police report, the medical
investigator report, nor the emergency response report note any head trauma suffered by the Insured or that such trauma was the cause of death.  Dr. Cline-Parhamovich, the medical investigator, identified the cause of death as “[a]therosclerotic and hypertensive cardiovascular disease” with “[m]orbid obesity” as a “significant contributory condition,” and that the Insured’s death was “[n]atural.” Dr. Stuart Schlanger, the reviewing physician, concluded the Insured, “with a very high probability[,] suffered an out of hospital cardiac arrest” and “almost certainly fell after the cardiac arrest.” Dr. Schlanger also concluded that “there was no accidental bodily injury which caused or contributed to the insurer’s [sic] demise.”  Rather, the Insured’s “underlying atherosclerotic vascular disease” and “morbid obesity” “directly contributed to [the Insured’s] out of hospital cardiac arrest.”

According to Federal Rule 56, summary judgment is proper when the pleadings and evidence on file show that no genuine issue exists as to any material fact and that the moving party is entitled to judgment as a matter of law.  To demonstrate a genuine issue as to the material facts, the nonmoving party must do more than simply show that there is some metaphysical doubt as to the material facts.  The nonmoving party must show that the evidence is sufficient to support the resolution of the material factual issues in his favor.

In this case there is no evidence an accident, i.e., the fall caused the death of the insured.  No autopsy was performed.  No one was present when the death occurred with the exception of the insured’s wife being in an adjoining room and, according to other records, she heard a “thud” and then found the insured on the floor but the wife died of natural causes before any testimony was able to be obtained from her.  However, the medical persons who responded did not note anything indicating other than the wife heard a thud and found her husband non-responsive.

The wording of the policy is relevant.  The Policy contains both a “sole cause” clause and an “exclusionary” clause. Under the sole cause clause, an injury (which “is the direct result of an accident or trauma”) must “result in loss independently of sickness and all other causes.” Under the exclusionary clause, the Policy explicitly bars coverage for “death resulting directly or indirectly from disease or bodily infirmity.” Under such clauses, the burden is on the insured to prove that the loss in question was caused by an accidental bodily injury directly and independently of all other causes.  Once the insurer has proven that an exclusion applies, the burden shifts back to the insured to show that the claim falls within an exception to the exclusion.

According to Texas law, “‘Independent’ as used in the [sole cause] clause means ‘solely,’ ‘only,’ and ‘standing alone.’”  Thus, a coverage clause of this
type limits recovery to accidental bodily injuries that are the sole cause of death.

The Court went into greater detail of the facts of the case and is a good read.  Plaintiffs simply had no evidence other than an abrasion of the forehead of the deceased with no explanation of how it got there or even when it actually occurred.

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