The Eighth Circuit Court of Appeals recently affirmed Life Insurance Company of North America (LINA) denial of accidental death benefits to the husband of an Iowa nurse who died of an overdose.
The court held that LINA reasonably interpreted the Policy’s coverage exclusion for voluntary “ingestion” of any narcotic in denying a claim for accidental death benefits.
At the time of her death, Marie Richmond had been working as a registered nurse for almost 20 years. A few hours after work one day, Marie was found unresponsive in her bedroom with needle punctures on her limbs and various narcotics nearby. Following his wife’s death, Jay Richmond submitted a claim for accidental death benefits from LINA.
In part, LINA’s Policy provided that benefits are paid only for deaths resulting from a “Covered Accident” that is unforeseeable and not otherwise excluded under the terms of the Policy. The relevant exclusion here is that benefits will not be paid for a death that is caused by or results from the voluntary “ingestion” of any narcotic or drug.
After receiving and reviewing the evidence, LINA denied Mr. Richmond’s claim on two separate grounds. First, LINA determined that the voluntary ingestion exclusion applied. Second, LINA decided that Marie’s death was not a Covered Accident because death was a reasonably foreseeable result of self-injecting a mixture of controlled substances.
After submitting two internal appeals to LINA in which he unsuccessfully argued that intravenous injection is not the same as ingestion, Mr. Richmond filed a lawsuit in federal district court where the judge agreed with both of LINA’s reasons for denying the claim. Mr. Richmond then appealed to the federal appellate court.
The Eighth Circuit Court of Appeal’s Review of Mr. Richmond’s Claim
Standard of Review
Like most claims for accidental death benefits, Mr. Richmond’s claim was governed by the Employee Retirement Income Security Act of 1974 (ERISA). If you are an eligible participant in your employer’s accidental insurance plan, it is likely governed by ERISA.
As with most ERISA plans, the policy granted LINA with discretionary authority to interpret plan provisions and determine a claimant’s eligibility for benefits. Under ERISA, if a plan document includes discretionary language, the court will apply an arbitrary and capricious standard of review. Under this standard, the court can only rule in your favor if it finds the insurance company had no reasonable basis to deny benefits. This is a difficult standard to meet compared to a de novo standard of review where the court makes an independent decision without needing to give any deference to the insurance company’s decision.
Indeed, as the court here explained, “any reasonable decision will stand even if we would have found differently in the first instance.” LINA, however, had the burden of proving that the voluntary “ingestion” exclusion correctly applied. Our experienced lawyers can help you better understand your policy and which standard of review applies to your claim.
The Court’s Decision
To determine whether LINA’s interpretation of “ingestion” was reasonable, the court used a five-factor test to analyze whether LINA’s interpretation:
- Is consistent with the goals of the Plan;
- Renders any language in the Plan meaningless or internally inconsistent;
- Conflicts with ERISA’s substantive or procedural requirements;
- Is consistent with how it has previously interpreted the words at issue; and
- Is contrary to the clear language of the Plan.
After weighing all five, the court found that the factors tilted slightly in LINA’s favor and concluded that it had offered a reasonable interpretation of “ingestion.” In addition, the court held that since LINA’s application of its interpretation to the facts was supported by substantial evidence, there was no need to address the issue of whether Marie’s death was foreseeable.
Accordingly, the higher court affirmed the judgment of the lower court – agreeing with LINA’s decision to deny Mr. Richmond’s claim for benefits.
Help from an Attorney with Expertise in Accidental Death Claims
Accidental Death insurance law is complicated. If your claim for accidental death benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in this area of law.
- Our lawyers specialize in accidental death insurance;
- Our lawyers have experience with LINA, UNUM, Hartford, CIGNA, Reliance Standard, and just about every other insurance company;
- Our lawyers have won tough insurance lawsuits;
- Our lawyers have recovered millions in accidental death, life, and disability benefits for clients who were wrongly denied or terminated.
Because federal law applies to most accidental death insurance claims, we do not have to be located in your state to help.
Dabdoub Law Firm represents clients nationwide with:
- Submitting a disability insurance claim;
- Appealing a long-term disability denial;
- Negotiating a lump-sum settlement; or
- Filing a lawsuit against your disability insurance company.
Call today to speak with an accidental death insurance attorney. No fees or costs unless clients are paid.