Prudential Life Insurance Company Awards Accidental Death and Dismemberment Insurance Benefits to Widow on Appeal After Denying Benefits Based on a Sickness or Illness Exclusion
The facts:
Our widowed Texas client’s husband drowned in a hotel swimming pool while swimming laps for exercise.
The autopsy report stated that the victim suffered a heart attack and drowned, but it did not answer the critical question of whether the cardiac event would have caused his death by itself if he had not been in the water.
The denial and exclusion:
Prudential Life Insurance Company denied the claim for accidental death benefits based on the following exclusion:
This Coverage pays benefits for accidental Loss [death] which results from an accident…
Benefits for accidental Loss are payable only if all of these conditions are met:
(1) The person sustains an accidental bodily Injury [lungs filled with water]…
(2) The Loss [death] results directly from that Injury and from no other cause.
Losses Not Covered:
A Loss is not covered if it [the Loss, death] results from any of these: …
(3) Sickness, whether the Loss results directly or indirectly from the Sickness.
The appeal:
We retained a highly qualified physician specializing in cardiac electrophysiology, a subspecialty of cardiology, to review the evidence and address the exclusion Prudential relied on. After considering the medical records, autopsy findings, witness information, and the policy language, the expert concluded that even if a cardiac event occurred first, the more likely medical explanation was not that the heart event independently killed him. Rather, the cardiac episode likely caused him to become impaired while in the pool, which led to the drowning.
The expert agreed that a medical event may well have preceded the drowning. But he explained that the available facts did not support the conclusion that the medical event itself was necessarily fatal. The insured had a history of coronary artery disease and prior cardiac issues, but the circumstances in the pool mattered. He was described as a good swimmer. He experienced a sudden struggle in the water. There was no evidence of an acute myocardial infarction. His blood glucose was normal when emergency responders arrived. Taken together, the expert believed the most probable precipitating event was some type of cardiac arrhythmia.
The expert identified two arrhythmia scenarios as medically plausible. One possibility was ventricular tachycardia. Given the insured’s prior cardiac history, including coronary disease, an old myocardial infarction with scarring, premature ventricular beats, and a prior short run of nonsustained ventricular tachycardia, such an episode could have occurred. But the expert explained that if ventricular tachycardia was the trigger, it was more likely a survivable rhythm disturbance rather than an immediately fatal event. On land, such an episode could have produced serious symptoms and required medical attention, but it would not necessarily have caused death.
The expert also explained why the facts did not fit well with primary ventricular fibrillation, which is a classic sudden cardiac death rhythm. The insured apparently struggled in the water for some period of time and still had a pulse and some spontaneous breathing when emergency personnel arrived, even though his airway and lungs contained water. Those circumstances were not what the expert would expect if the first event had been sudden, fatal ventricular fibrillation.
A second possible trigger was paroxysmal atrial fibrillation. The insured had several risk factors for atrial fibrillation, including coronary artery disease, prior myocardial infarction, hypertension, obesity, and a history of moderate alcohol use. An episode of atrial fibrillation could have caused enough weakness, shortness of breath, lightheadedness, or disorientation to make him inhale or swallow water, beginning the drowning process. But atrial fibrillation itself would not ordinarily be fatal if it occurred while the person was safely on dry land.
The expert’s ultimate opinion was that the insured’s death was not likely caused directly by sickness or heart disease alone. Instead, a medical event may have impaired him just enough to place him in danger while swimming. Had the same event happened outside the pool, the expected symptoms likely would have been chest discomfort, shortness of breath, near-fainting, fainting, or a need for medical evaluation. Even assuming a more serious rhythm disturbance requiring resuscitation, the chances of survival would have been materially better on land because help could have begun sooner, his airway and lungs would not have been filled with water, and resuscitation would not have been complicated by drowning.
In short, the expert explained that the location of the event changed the outcome. The presumed medical event may have caused the struggle, but the drowning caused the death. Because the episode occurred in a swimming pool, what might otherwise have been a survivable cardiac event became fatal.
The outcome:
Prudential reversed its denial and awarded our client all benefits.
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, she was able to secure the deserved benefits.Â
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.Â
It was an honor to help our client overturn such an unfair claim denial.
Results may vary. Every case is different, and no outcome can be guaranteed.
