Accident – the name of the Insurance – Needed to Obtain ADD Benefits

Insurer Reasonably Concluded that Death from Natural Causes not an Accident

Life is a terminal disease from which all humans suffer. We all die eventually. Accidental Death and Dismemberment insurance (AD&D) only responds when the death or dismemberment is due to an accident. That simple, clear and unambiguous provision results in litigation even when there is an autopsy report revealing that the death was due to natural, non-accidental causes.

In Linda Grabowski v. Hartford Life & Accident Insurance Company, BAE Systems Funded Welfare Benefit Plan; BAE Systems Administrative Committee; BAE Systems, Inc., No. 17-2108, United States Court of Appeals for The Fourth Circuit (September 4, 2018) Linda Grabowski (Linda) tried to collect after her husband died from natural, non-accidental causes. The trial court denied her motion for summary judgment and granted the summary judgment to Defendant Hartford Life and Accident Insurance Company (Hartford). Linda challenged  Hartford’s decision not to pay AD&D benefits under an ERISA employee benefit plan following the death of her husband Mark Grabowski (Mark).

FACTS

On April 15, 2013, Mark flew from Binghamton, New York, to Los Angeles, California, as part of a business trip for his employer. Two days later, he collapsed and died at his employer’s Los Angeles office. Linda applied for benefits under the policies available from Mark’s employer. Hartford denied her claims on the bases that Mark’s death did not result from a traumatic accidental injury independent of all other causes and was caused or contributed to by sickness or disease. The district court affirmed the denial of benefits and granted summary judgment to Hartford.

ANALYSIS

Hartford had discretionary authority to determine eligibility for benefits under the plan’s AD&D policies and to construe and interpret terms and provisions therein. Where an ERISA plan grants an administrator discretion to award a benefit, a court must review its decision only for abuse of discretion and must not disturb the decision if it is reasonable, even if the appellate court would have reached a different conclusion. A plan administrator’s decision is reasonable if it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence.

When reviewing the administrator’s findings for substantial evidence, the Fourth Circuit’s review is limited to a review of the evidence that was before the plan administrator at the time of the decision. When an administrator has interpreted a plan’s terms, we do not construe ambiguities against the insurer who drafted the terms.

The Fourth Circuit applied the following in determining if the decision of the District Court was appropriate:

(1)       the language of the plan;

(2)       the purposes and goals of the plan;

(3)       the adequacy of the materials considered to make the decision and the degree to which they support it;

(4)       whether the fiduciary’s interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan;

(5)       whether the decision making process was reasoned and principled;

(6)       whether the decision was consistent with the procedural and substantive requirements of ERISA;

(7)       any external standard relevant to the exercise of discretion; and

(8)       the fiduciary’s motives and any conflict of interest it may have.

Under the abuse of discretion standard Hartford only had to offer a reasonable, and not the most reasonable, interpretation of plan terms.

The policies under the plan condition AD&D benefits on the presence of an “accidental injury” and a “bodily injury resulting . . . directly from an accident.” Hartford determined these circumstances were not present because Mark died from the natural cause of a pulmonary embolism in the absence of any trauma.

Linda complains about Hartford’s claims review process, noting that it was performed by a benefits specialist, without input from or analysis by a medical professional but was unable to show that the specialist did not fairly interpret the facts and the policy. Rather, the Fourth Circuit concluded, after completing its analysis, that Hartford did not act unreasonably in determining that Mark’s death was not an accident or accidental under the policies. The Fourth Circuit also concluded that any lack of proof on this point has no bearing on the outcome of the case.

ZALMA OPINION

Mark died because a foreign body (an embolism), such as air bubbles or blood clots, blocked blood flow in his arteries. There are different types of embolism, including brain embolisms and Mark’s pulmonary embolism that stopped blood flow to his lungs and killed him. It was reasonable for Hartford to conclude his death was not due to an accident and, therefore, it owed nothing on the AD&D policy.


© 2018 – Barry Zalma

This article, and all of the blog posts on this site, digest and summarize cases published by courts of the various states and the United States.  The court decisions have been modified from the actual language of the court decisions, were condensed for ease of reading, and convey the opinions of the author regarding each case.

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant  specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 50 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.

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About Barry Zalma

An insurance coverage and claims handling author, consultant and expert witness with more than 48 years of practical and court room experience.
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