ERISA And Life Insurance And Accidental Death Coverage

Fort Worth lawyers who handle ERISA claims will need to read this opinion out of the U.S. District Court for the Southern District of Texas, Houston Division. It is styled, Sandra James v. Life Insurance Company of North America and Geico.
This is an appeal of a Magistrates ruling on a summary judgment in favor of Life Insurance Company of North America and Geico (Geico).
Sandra’s husband was killed in a one vehicle accident with a tree and subsequent fire. The medical examiner stated Robert’s cause of death was “inhalation of combustion products and thermal injury.” The listed manner of death was an “accident.”
Robert was insured under an ERISA plan with his employer Geico. The policy provided accidental death benefits of $300,000.00.
The policy’s AD&D benefits were triggered when “the Covered Person suffered a Covered Loss resulting directly and independently of all other causes from a Covered Accident . . . .” A “Covered Accident” was defined as a “sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or a Covered Loss” that is “not contributed to by disease, Sickness, or mental illness,” and “is not otherwise excluded” by the policy.
Sandra made a claim for benefits.
Geico denied Sandra’s claim. Geico found that the crash was not “unforeseen” as required by the policy, because it was caused by Robert’s driving under the influence with a blood alcohol concentration (“BAC”) of 0.19%, a level more than two times above the legal limit. Geico reasoned that because studies have shown that individuals with BACs between 0.11 and 0.20 percent suffer serious physical impairments including slowed reaction time and gross motor control, Robert’s death was not an unforeseen event while he operated a motor vehicle with a BAC at the high end of that range.
In ruling in favor of Geico, the magistrate Judge cited several reasons, one of which had to do with the per se rule of intoxication.
As to the Magistrate Judge’s finding that a per se rule was used in Geico’s determination, Geico object that because it considered not just that Robert’s BAC level was over the limit, but that it was in one of several different ranges above the legal limit, that shows Geico did not use a per se rule. Geico also claims that other factors were considered such as roadway conditions and the weather.
Though Geico concluded that “serious injury or death would be highly likely to occur while operating a vehicle with a BAC of .19% and would not be an unforeseen event,” the reasoning of the denial simply listed common side effects of having a BAC of .19 and, based on these side effects, concluded that Robert’s death was highly likely. Based on the conclusion that the injury was highly likely, Geico concluded that the accident was foreseeable. The court did not find this persuasive, particularly when considering whether it is reasonably foreseeable that such injury or death would be highly likely. More persuasive is a Sixth Circuit opinion which reviews 2003 National Highway Traffic Administration statistics that compared the amount of alcohol impaired trips that were taken to the amount of people who died (0.17 percent). It cannot be reasonably said that a less than one percent chance of death makes death reasonably foreseeable, much less highly likely. Certainly, there are points under which this analysis might differ from the case at hand but it supports the conclusion. This reasoning is not meant to dismiss the tragic consequences that drunk driving can create or the diminish the responsibility drivers must take for their actions, it simply points out that this conclusion does not comport with how an average person would interpret the policy.
This case is a definite victory for policy holders.