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Accidental Death Benefits Claim Through ERISA

“ERISA MAY Also Apply to a Claim for Accidental Death Benefits”  We usually see the application of ERISA to a claim for short term or long term disability benefits or to a claim involving health benefits.  The recent case of Nichols v. Unicare Life and Health Insurance Co., decided January 16, 2014, by the Eighth Circuit shows that the reach of that statute can also apply to a claim for accidental death benefits.  In this case, the deceased wife had been taking several prescription medications and died as a result of the combination of them.  The insurance company denied death benefits on the basis of an intoxication exclusion and the husband filed suit.  The district court granted the benefits, finding that the deceased wife did not intend to die as a result of taking the medications and that her death was the result of an accident.  The Eighth Circuit affirmed the ruling noting that the insurance company had “ignore[d] the subjective evidence submitted by Nichols, and instead makes leaps to get to the `objective` conclusion it desires.” (opinion at p. 9)  The Court further noted that there was “no evidence whatsoever that Dana intended to kill herself or thought it likely she would die on May 3, 2010. The subjective evidence, in the form of letters and statements from her husband and parents, suggests otherwise.” Id.  The Court also noted that the word accident had not been defined in the policy, and therefore, the wife’s death could be viewed as the unexpected result of ingesting medications and fit within that term’s meaning.

Although this is an ERISA claim involving accidental death benefits, one can draw some parallels between this type of claim and a claim for long term disability benefits under ERISA.  The lawyers at Burke Harvey typically submit affidavits, declarations, and statements of the claimant and their family members and co-workers as part of any appeal.  This “subjective” evidence allows the claimant to frame his or her condition in testimony that is based on direct observation.  Second, to the extent a term or phrase in an insurance policy is undefined, the doctrine of  Contra proferentem (Latin: “against [the] offeror”), also known as “interpretation against the draftsman”, provides that the preferred meaning should be the one that works against the interests of the party who provided the wording.  Having a lawyer involved at the appeal stage will ensure that any policy language regarding the definition of “disability’ will be examined before the final appeal has been filed. If you are submitting an appeal for long term benefits feel free to call the lawyers at Burke Harvey for help.