Losing a loved one to an accidental death can be devastating. That devastation can be compounded further when an insurance company refuses to pay accidental death and dismemberment (AD&D) benefits. A common practice of insurers is to deny AD&D claims based on exclusions contained in the policy, like an intoxication or a self-inflicted injury exclusion. Insurers often attempt to interpret such exclusionary provisions more broadly than allowed for by the policy language and more broadly than the law allows. The Eighth Circuit Court of Appeals recently addressed this issue in Yates v. Symetra Life Insurance Company, — F.4th –, 2023 WL 2174840 (8th Cir. February 23, 2023).

After her husband died of a heroin overdose, Terri Yates, the Plaintiff, made a claim with Symetra Life Insurance Company for accidental death benefits under an ERISA plan. Symetra denied her claim, and she sued. First, the court found that Plaintiff’s suit was not barred because she failed to exhaust administrative remedies under ERISA. A discussion of how and why the court found that Plaintiff was not precluded from suing for failure to exhaust administrative remedies is found in a separate article found on our blog here. Next, the court analyzed Symetra’s denial of Plaintiff’s claim based on an exclusion in the policy which stated that Symetra will not pay for any loss caused by “intentionally self-inflicted injury.”

Symetra’s reasoning in denying Plaintiff’s claim was that her husband had died of a heroin overdose, and because he had intentionally consumed the heroin, his resulting death was therefore also intentional. The court disagreed and found that Symetra’s denial of Plaintiff’s claim was erroneous. First, the court established that because Symetra’s denial was based on an exclusion to coverage, it had the burden of proving that the exclusion applied. Nichols v. Unicare Life & Health Ins. Co., 739 F.3d 1176 (8th Cir. 2014).

The court then identified the issue: whether Plaintiff’s husband’s overdose “injury” “intentionally self-inflicted.” Yates v. Symetra, supra, at 11. The court cited a case in which the decedent had a blood-alcohol level in excess of the legal limit when he died in a motorcycle accident. King v. Hartford Life & Accident Insurance Co., 141 F3d 994 (8th Cir. 2005). In King, the court found that it was unreasonable for Hartford to apply the policy’s “intentionally self-inflicted injury” exclusion because the most natural reading of the exclusion was that it did not include “injuries that were unintended by the [plan] participant, but which were contributed to by alcohol intoxication.” Id. at 1004. The court reasoned that the proper inquiry was not whether drinking alcohol to the point of intoxication was intentionally self-inflicted, but rather, whether the injuries resulting from the motorcycle crash were intentionally self-inflicted. Id. The court found that because the decedent “did not intend to injure himself by driving his motorcycle,” the injuries were not intentionally self-inflicted. Id. Applying this reasoning to Yates, Symetra needed to demonstrate that Plaintiff’s husband not only intentionally used the heroin that caused him to overdose, but also that he intended to cause his own death by using the heroin.

The court discussed Symetra’s argument that the exclusion applied because Plaintiff’s husband “purposely” used heroin. The court reasoned that “just because the act of using an illegal substance was purposeful does not mean that an injury stemming from the act, including a fatal overdose, was too.” Id. (emphasis original)(citing Kovach v. Zurich Am. Ins. Co., 587 F.3d 323, 339 (6th Cir. 2009)). The court acknowledged that “using heroin is undoubtedly risky, much like driving while intoxicated.” Yates, supra¸ at 13. However, the issue the court found to be determinative was that “whether an ‘intentionally self-inflicted injury’ exclusion applies depends on whether the injury in question was indeed intentional.” Id. The court found that “it does not depend on whether the injury was generally foreseeable or even likely, or whether the injury-causing conduct was risky or even reckless.” Id. at 14. Rather, the court found that for such an exclusionary clause to bar Plaintiff from receiving AD&D benefits, Symetra must demonstrate that the decedent in fact intentionally caused his own death. Since Symetra could not demonstrate that, the court found in Plaintiff’s favor.

You may still be entitled to benefits even if an insurer has denied your AD&D claim based on a policy exclusionary provision. If an insurer has denied your claim for AD&D benefits, the experienced life and accidental death insurance claim attorneys at McKennon Law Group PC can assist you to determine whether the insurer has properly applied an exclusion or is improperly invoking exclusionary language to avoid paying you the benefits to which you are entitled.