Accidental Death Insurance Benefit Denial by Prudential Under Intoxication Exclusion Reversed on Appeal
A Tragic Fall While Alcohol-Intoxicated, but Not “Caused By” Intoxication
Our client Lisa (not her real name), had her accidental death insurance claim denied by the ERISA Initial Claim Administrator after her husband George died from a fractured skull and brain bleed injury. He fell down their home stairway into the basement in Clinton, Michigan at 11 PM on a Saturday night after a few beers.
There were two witnesses to George’s fall – Lisa and their cat Sinbad (for identity protection, not his real name either).
Toxicology results showed George had a blood-alcohol level of .238, nearly three times the Michigan legal driving limit of .08.
The Policy Exclusion for Intoxication
The claim was denied under a Prudential policy exclusion which read: “A loss is not covered if it results from any of these:… 11. Being under the influence of alcohol or alcohol intoxication, including but not limited to having a blood alcohol level above the limit for permissible operation of a motor vehicle in the jurisdiction where the lost occurred, regardless of whether the person: (a) was operating a motor vehicle; and (b) was convicted of an alcohol related offense.”
Lisa testified that she and George woke up early in the morning, and each worked from 7:00 AM on the accident date, returning home from their respective jobs at 3:00 PM. They attended a nearby family barbeque from 4:30 PM until returning home together at 9:30 PM. At the barbecue, George drank three 12- ounce light beers.
When they got home, their power was out, so they sat outside on their patio to stay cool until 11:00 PM, where George had three or four more 12-ounce light beers, before deciding to go inside to bring their dog and cat outside. The power was still out.
George approached the darkened outside landing of the door to the house, located at the top of a stairway which leads down to their basement, and opened the door. As he took his first step down, Sinbad, mostly black in color, came running up the dark-carpeted stairway. In an attempt to avoid kicking or stepping on the cat, George tripped and fell down the stairway. Sinbad was a bit shaken up, but OK with eight lives left.
Lisa testified that the amount of alcohol George consumed that night was routine for him on a Saturday, and he was very tolerant of such an amount. He showed no signs of slurred speech, unsteadiness in his walking or any other signs of intoxication when he tripped over Sinbad.
The Burden of Proof is Everything
We presented Lisa’s testimony, testimony of others at the barbeque, photos of the dark stairs and dark Sinbad, records of the power outage, and the opinion of a toxicology expert on the tolerance and causation issues. Our expert didn’t go so far as to say that more likely than not the alcohol was not a contributing factor. But he convincingly opined that under the undisputed facts (again, only two living witnesses, and Sinbad took The Fifth), no toxicologist could reasonably opine that the accident could not have happened in the absence of the alcohol.
With Prudential bearing the burden of proof on its exclusion, and the policy exclusion requiring a causal link between the alcohol and the fall, the ERISA Plan Appeal Administrator reversed the Initial Claim Administrator’s denial of the claim. Widow Lisa got her deserved benefits for which George had paid premium for years to protect her.
Victims Of Unfair Insurance Denials Should Always Appeal Unfair Claim Denials
In the end, because our client continued to fight, appealing the insurance company’s denial rather than just accepting it as the final word, was able to secure the deserved benefits.
Unfortunately, insurance companies unfairly deny legitimate claims every day. But anyone faced with an unfair claim denial should continue to fight and appeal the denial. These unfair denials can be overturned with stronger evidence, properly presented.
It was an honor to help our client overturn such an unfair claim denial.
