Accidental Death Insurance Claim Denied

Accidental Death Insurance claim denials are all too common.  This type of insurance is usually very inexpensive.  This is for a couple of reasons.  One is the vast majority of people die for reasons unrelated to an accident.  The other is the policies have exclusionary language in them excluding coverage for deaths that most would consider to be accidental but they are not covered because of the exclusionary language.  A common example is an exclusion for an accidental death involving drugs or alcohol.

Here is a case that does not involve drugs or alcohol.  Its exclusionary language is different.  This is a 2022 opinion from the Eastern District of Texas, Sherman Division.  It is styled, Shemily Ortiz v. Reliastar Life Insurance Company.

The deceased, William Ortiz, had an accidental death policy with Reliastar.  Upon his death, Shemily made a claim for benefits that was denied by Reliastar based on their contention that Williams death was not covered under the language stating there is no coverage for death “directly or indirectly caused by … Physical or mental illness.”

A lawsuit was filed and this summary judgement was filed by Reliastar.  The Court denied the summary judgment.

William was involved in a minor car wreck on March 25, 2018.  The next morning he was experiencing a “thunder clap” headache, collapsed, was unable to communicate, and was taken to the hospital and ultimately died.

After the wreck, William’s two sons were asked by William to not tell Shemily about the wreck because he did not want to upset her.

Immediately after the wreck there is testimony about William beginning to act strangely.

The next morning when first responders were called to his house due to his thunderclap headache, Shemily was asked whether anything had recently happened to William.  Not knowing about the previous days’ accident she said no.  The result of not mentioning the accident is that there are no medical records attributing the accident to William’s complaint.

A CT scan at the hospital revealed a subarachnoid hemorrhage (SAH).  Further diagnosis revealed an arteriovenous malformation (AVM) in Williams brain, a defect he was born with.  An expert hired by Shemily, Dr. Meisamy, testified how it could be the accident that caused the SAH and that the AVM had nothing to do with it.

Reliastar denied the claim based on its assertion that the AVM directly or indirectly caused Williams death, not solely the wreck the day before.

Here is what the Court said:

ReliaStar seeks summary judgment because it claims Ortiz has not and cannot meet her burden of showing that William’s death was an “accident” that is payable under the Policy.  Accordingly, ReliaStar argues it is not, as a matter of law, liable to her under any of the causes of action she brings.  Ortiz submits there are genuine disputes as to material facts that a jury must decide.  Specifically, Ortiz expects Dr. Meisamy to explain the lack of medical bills referring to William’s trauma, discuss the details of an AVM, and testify that the symptoms William exhibited immediately following the accident are symptoms associated with an SAH.  Such evidence, she claims, should be left for the jury to hear and weigh because it contradicts ReliaStar’s evidentiary assertions.

For a claim to be accepted under the terms of the ReliaStar Policy, two requirements must be met.  First, the death must be an accident and, second, the cause of the loss must not be excluded.  The parties submit conflicting factual evidence regarding the causation between the car accident, William’s underlying AVM, and William’s death.  To be sure, filtering through the evidence submitted by both parties requires the Court to engage in weighing the evidence—a task with which the Court must not engage when deciding a motion for summary judgment.  Resolving all reasonable doubts in favor of Ortiz, a reasonable jury could find credible Dr. Meisamy’s testimony, which could affect ultimate determinations as to causation of William’s death.

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