DeBofsky Sherman Casciari Reynolds P.C. (2024)

Accidental death insurance, also known as (AD&D) insurance, is a type of insurance that supplements basic life insurance coverage. AD&D insurance pays benefits in addition to life insurance if the insured dies as a result of an accident or suffers a catastrophic injury that results in limb amputation or loss of vision or hearing. Most employers who sponsor group life insurance for their employees include accidental death coverage as well, but so long as individuals purchase sufficient life insurance to cover their family’s financial needs, there is no reason to purchase additional AD&D coverage since there is a statistically low probability of accidental death.

When accidental deaths occur, though, typical causes of accidental death or dismemberment claims are motor vehicle accidents, falls, poisoning, drowning, and gunshot injuries. Death by homicide is also considered an accidental death. But not every death resulting from such causes would be considered accidental. Intentionally inflicted injuries are excluded, as is suicide. Likewise, if someone is killed while engaged in illegal activities, it is generally not viewed as an accidental death for insurance purposes. Nor would someone who dies while undergoing medical treatment be considered to have suffered an accidental death.

What AD&D Claims are Covered?

The key to accidental death coverage is the principle stated in Wickman v. Northwestern National Insurance Company,a seminal federal appellate court ruling explaining that insureds purchase accident insurance “for the very purpose of obtaining protection from their own miscalculations and misjudgments.” Even if someone engages in a potentially hazardous activity, death or catastrophic injury would be covered under the principle that the injury was neither expected nor intended and that there was a subjective expectation of survival. Most jurisdictions also apply a presumption against suicide, so if there is uncertainty as to whether, for instance, an overdose of prescription medication was unintentional or deliberate, the absence of a suicide note would likely lead to a conclusion the death was accidental. Death occurring as a result of autoerotic asphyxiation may be an exception, though, since courts have reached differing conclusions on whether death occurring under such circ*mstances is accidental. Some courts have found a subjective expectation of survival constitutes a sufficient basis for deeming the death accidental, while other courts find a partial strangulation that goes too far and ends in death was intentional and precludes recovery.

How is Accidental Death Coverage Determined?

The amount of coverage varies. Typically, accidental death insurance benefits are in the same amount as life insurance benefits, although it may be possible to purchase more coverage. For dismemberment, benefits are usually paid as a percentage of the total amount depending on the specific loss. Thus, for example, a leg amputation may allow for recovery of 50% of the benefit amount, while a double amputation could result in a 100% recovery.

Typical Exclusions in Accidental Death & Dismemberment Policies

Some activities are so fraught with potentially fatal risk that most policies exclude coverage for them. Examples include:

• Driving under the influence of alcohol or narcotics
• Overdoses of illicit drugs or even legal drugs if used without a prescription
• Skydiving or bungee jumping
• Injury suffered while participating in a war. Some policies go so far as to even exclude deaths that occur in a war zone regardless of whether the insured was a combatant

Accidental death insurance policies also exclude deaths that occur from illness or disease, even if the death was sudden and unexpected, such as from a heart attack. An exception, though, would be if the insured suffers an accidental injury and then dies after an intervening event such as surgical treatment. An example would be a death occurring following a sports injury that requires treatment. However, the general rule is that someone who dies while undergoing medical treatment for an illness would not be considered to have suffered a compensable accidental death. If, however, a patient undergoing treatment in a hospital dies as a result of a piece of equipment falling on him or her, that would not be excluded.

Another situation that could result in recovery of accidental death benefits is if someone dies from an illness that is contracted due to an external event. A cut may result in a fatal infection if caused by a contaminated object such as a nail. But if someone has an underlying medical condition such as an acute allergic reaction to a bee sting, death due to anaphylaxis resulting from a sting might not be covered. Nor would contracting a fatal illness such as Covid-19 while going about everyday activities.

Even exclusions relating to commission of a crime can be complicated. Driving in excess of the speed limit or failing to stop at a stop sign would probably not fall within the exclusion; reckless driving would.

Causation: Accidental Death or Underlying Medical Conditions?

The hardest accidental death insurance claims are those that involve individuals with underlying medical conditions that may play a factor in a resulting death. Most policies are worded to require that death must occur as a result of an accident independent of all other causes. However, courts have ruled that someone who suffers a seizure while driving, loses control of their car, and suffers fatal injuries is entitled to accidental death benefits. Likewise, individuals who have underlying conditions such as diabetes may be able to recover dismemberment benefits if they are involved in a traumatic accident that leads to an amputation that was in part the result of diabetes. Drownings that occur when someone falls into a body of water on account of an underlying medical condition are usually deemed accidental unless death would have resulted from the condition had there not been any water present. The court’s reasoning in such cases is that the proximate cause of death is the injury resulting from the trauma rather than from the underlying condition. Some recent cases, though, have departed from a precedent that is more than a century old and have concluded that if the trauma such as a car collision would not have occurred but for the underlying medical condition, there is no accidental death coverage.

In many of these cases, the policy language is the determinant of the outcome. The broader the exclusion, the weaker the coverage. Courts have also reached differing conclusions on which party bears the burden of proving that death was due to an accident or disease.

Conclusion: Accidental Death Claims is Complicated

This discussion should make it clear that accidental death insurance claims can be very complicated. Most situations are clear cut, i.e., a car accident where drugs or alcohol are not a factor, a fall from a ladder, or unwittingly consuming a poisonous substance. But other cases are not so easily classified as an accidental death, especially if the insured suffered from an underlying condition that played a factor in the resulting death or dismemberment. Results vary from case to case and in different jurisdictions.

Rather than simply accepting a decision from an insurance company that denies an accidental death and dismemberment claim, though, beneficiaries should seek advice and counsel from a knowledgeable and experienced attorney who is familiar with the issues and the law and who can help evaluate the claim and pursue litigation if warranted.