Chicago area employees with coverage under an ERISA governed accidental death insurance policy often wonder the distinction between life insurance and accidental death insurance when a person dies of a sudden medical event, such as a heart attack or pulmonary embolism. There is no doubt these are events qualifying a beneficiary for life insurance benefits, absent a pre-existing condition or other exclusion, but the law can be murky about whether the resulting death is an accidental injury. The outcome will invariably be highly dependent on the specific facts of the case and the specific language of the policy. The possible variation in results cannot be evidenced better than in opposite results in two cases based upon the same Chicago resident’s death under two different accidental death insurance policies.
Just yesterday, the United States District Court for the Northern District of Illinois denied Reliance Standard Life Insurance Company’s motion for summary judgment in Yasko v. Reliance Standard Life Insurance Company, No. 12-2658. There, Dr. Yasko, an orthopedic surgeon, suffered from lung cancer and underwent surgery to address it. Six months later, while on a flight to Mexico, Dr. Yasko suffered a pulmonary embolism, and died the next day as a result. Reliance Standard denied the claim, contending the death was not an accident, and that Dr. Yasko’s lung cancer contributed to the death. Under the policy, the term “accident” was not defined. Additionally, the policy excluded losses where “sickness, disease, or myocardial infarction, including medical or surgical treatment thereof, is a contributing factor.” Because “accident” was undefined, the court held the ambiguity must be construed against the insurer. Additionally, Reliance Standard could have written pulmonary embolisms into the exclusion, as it did with myocardial infarctions, but chose not to do so.
The court noted the opposite results for the same claim under a different policy. The difference was the other policy contained a discretionary clause, which gave another insurer discretion to interpret any ambiguous terms of the plan and determine eligibility for benefits. This particular policy, however, contained no such grant of discretion, explaining the different results.
If you have questions about a claim for accidental death insurance benefits, or your claim for accidental death insurance benefits has been denied, call an experienced ERISA attorney today.