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Underlying Medical Conditions Can Complicate Accidental Death Insurance Claims

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Underlying Medical Conditions Can Complicate Accidental Death Insurance Claims

20 Feb, 2021
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Beneficiaries of life insurance and accidental death insurance policies in Chicago often get a claim denied when an insurer sees there was a chronic medical condition. The insurer’s internal rationale was that the insured was high risk without the accident, so it must find a way to determine the loss was not caused solely by the accident. This interplay between the accident and a pre-existing medical condition causing the loss varies from one fact pattern to another, meaning there is seldom direct authority dictating the result.

In a case I once handled, the insured had stage 4 terminal cancer and was in a weakened state. While getting out of his bed to use the bathroom, he fell, and was so fragile it cracked his ribs. The cracked ribs led to a punctured lung, causing his death a few days later. Multiple accidental death insurers denied the claim, blaming the death on his cancer making him so weak that a simple fall resulted in his death. In that case, we were able to get all three policies to pay the claim, because the fact that a medical condition makes one more susceptible to suffering an accident did not bar the claim, and we had to explain the differences between accidental means and accidental results to the insurers. A recent claimant (not represented by me), did not get as good of a result.

In Byerly v. Standard Insurance Co., No. 20-40302, 2021 WL 364243 (5th Cir. Feb. 2, 2021), Bylerly suffered from diabetes and peripheral neuropathy. He tripped and stubbed his toe, which led to an amputation. The doctors all agreed that his diabetes contributed to requiring amputation. Standard denied his claim. When Byerly sued under ERISA § 502(a), both the district court and the Court of Appeals upheld Standard’s decision. The distinction in Bylerly’s case was that the illness did not make the accident more likely, but it did make the extent of the injury from the accident triggering a loss: a dismemberment. While the difference may seem subtle, it has great legal significance.

If you have a loved one who passed away by accident, or you experienced a dismemberment, talk to an experienced accidental death insurance lawyer about whether there is a covered loss. Timelines to challenge insurance denials for accidental death are as short as 60 days, and a successful appeal often requires analyzing medical records and potentially obtaining expert opinions. You have enough to handle in those 60 days with your loss. A good accidental death insurance lawyer can handle the insurer.

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