by Steve Fields | August 25th, 2022
August 25, 2022 – U.S. Court of Appeals – 9th Circuit – 46 F.4th 979
This was a claim brought by the estate of the decedent for payment of Accidental Death and Dismemberment benefits under a policy issued and insured by Life Insurance Company of North America (LINA, a/k/a Cigna, a/k/a New York Life Insurance Company). The decedent died in a one-car collision, and benefits under the policy under which he was insured were denied. The policy was supposed to pay a death benefit resulting from a “Covered Accident,” which was defined as “a sudden, unforeseeable, external event that results, directly and independently of all other causes.”
The claim was denied on the basis that the decedent died in a one-car collision while driving at a high speed, in the wrong direction down a one-way road, while intoxicated. The insurance company determined that the decedent’s death was a foreseeable outcome of his voluntary actions. The district court rejected the insurance company’s denial, and the Court of Appeals affirmed. This was a policy interpretation issue in which the Court determined that the appropriate test for whether the death was an “accident” should ask whether the resulting death was “substantially certain” to occur from the insured’s conduct. The court awarded the life insurance benefits to the estate of the decedent.
This case highlights the importance of seeking representation early on in a case. The estate prevailed due to the attorney’s early and effective representation beginning in the administrative appeal stage and carried out through the court of appeals. ERISA cases often involve nuanced arguments such as this policy interpretation issue, and it is important to have an experienced ERISA attorney on your side.
