Key Takeaways
- A Texas insurance professional, Mr. Sewell, was left paralyzed after a shallow-water diving accident during a fishing trip.
- Lincoln National Life Insurance Company denied Mr. Sewell’s Accident Death & Dismemberment (“ADD”) claim suggesting no benefit would be payable because of a disputed hospital blood test that suggested intoxication.
- The court found Lincoln ignored relevant evidence, including eyewitness testimony and expert reports, and operated under a conflict of interest.
- The court awarded Mr. Sewell his AD&D benefits.
Background: A Horrific Accident Caused Mr. Sewell to Become a Quadriplegic
In August 2021, 56-year-old insurance professional and Navy veteran, Timothy Sewell, joined friends for a fishing trip in Port Aransas, Texas. After a day of fishing, he dove into the water from his boat. His friends were already swimming in the water. The water where he dove was shallow, and Mr. Sewell struck a hidden sandbar, fracturing his neck and leaving him permanently quadriplegic.
Mr. Sewell filed a claim for Accidental Death & Dismemberment (AD&D) benefits with his insurer, Lincoln National Life Insurance Company. Lincoln denied the claim based solely on a policy exclusion related to alcohol use. Lincoln pointed to a hospital blood test that reported a blood alcohol concentration (BAC) of 0.222%.
Mr. Sewell submitted multiple affidavits from eyewitnesses stating he showed no signs of impairment and appeared in control. Mr. Sewell also submitted expert testimony that the hospital alcohol could not possibly be accurate. Lincoln ignored all evidence submitted by Mr. Sewell and instead relied entirely on the disputed hospital test.
Lincoln’s Flawed Review Leads to the Denial of Benefits
Lincoln cited the policy exclusion that denies benefits if alcohol is present which raises a presumption that the claimant was under the influence of alcohol and contributed to the cause of the accident. To reach its decision, Lincoln commissioned paid reviews, all of which relied heavily on the disputed blood alcohol test.
Lincoln’s first expert, who had worked with the insurer for more than 20 years, issued a report within one day and opined that Mr. Sewell was severely intoxicated. In response to Lincoln’s initial denial of benefits, Mr. Sewell appealed and submitted:
- An expert report authored by Dr. Thomas Arnold who disputed the test’s accuracy, calling it “egregiously flawed” and inconsistent with observed facts.
- Eyewitness testimony from multiple people who were present during the fishing trip confirming Mr. Sewell appeared sober and in in full control of his actions.
Lincoln dismissed these accounts, labeling them not credible, and doubled down on its position that alcohol caused the accident. Lincoln again hired a paid consultant who ignored Mr. Sewell’s evidence and relied on the blood alcohol test to suggest Mr. Sewell was intoxicated.
Court’s Analysis – Lincoln Abused its Discretion under ERISA
The US District Court for the Southern District of Texas found in favor of Mr. Sewell after finding that Lincoln’s denial was arbitrary and capricious. The court noted the following regarding Lincoln’s denial of benefits:
- The policy only created a presumption that a certain blood alcohol level indicates intoxication. The court noted that presumptions can be rebutted, and here this presumption was rebutted by eyewitness affidavits, medical evidence, and expert reports that Lincoln ignored.
- The court noted that without the disputed test, there was no credible evidence Mr. Sewell was intoxicated. The accident was more logically explained by environmental hazards, specifically the hidden sandbar. By relying solely on the blood test, Lincoln failed to ground its decision in substantial evidence.
- As both insurer and claims administrator, Lincoln operated under a financial conflict of interest. The court highlighted that Lincoln’s experts appeared adversarial rather than impartial, and that the insurer refused to consider Mr. Sewell’s additional evidence once he appealed.
Court Orders Approval of AD&D Benefits
The court was faced with one question – whether the blood test results alone provided evidence to support the decision to deny benefits when the administrative records contains significant evidence undermining the reliability of those test results. The court found there was not enough evidence in the record to find that Mr. Sewell’s accident was caused by intoxication. Instead, the court recognized the incident as a horrible and unfortunate accident caused by a hidden danger.
Why This Case Matters
This ruling shows that insurance companies cannot arbitrarily dismiss evidence supporting a claim for benefits. The decision emphasizes the following:
- A disputed or flawed toxicology result cannot be the sole basis for a denial, especially if the other evidence contradicts the test results.
- Eyewitness testimony and expert analysis can successfully rebut presumptions in insurance policies.
- Courts will scrutinize insurers who fail to engage in a fair and meaningful review of all evidence.
- Conflicts of interest can tip the balance against them in litigation.
How Dabdoub Law Firm Helps Claimants in Similar Cases
At Dabdoub Law Firm, we focus exclusively on disability insurance, life insurance, and AD&D claims.
- A nationwide practice representing clients in all 50 states
- A proven track record against every major insurance company, including Lincoln
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- Litigation strength in federal court and an unwavering commitment to our clients’ long-term well-being
Conclusion
The court’s decision in Mr. Sewell’s case issues a warning to insurance companies that it cannot disregard credible evidence in favor of predetermined outcomes. When horrific accidents occur, claimants deserve fair consideration of their claims. If your life or AD&D benefits have been denied under questionable circumstances, an experience law firm like Dabdoub Law Firm can make the difference in securing justice.
Disclaimer: Dabdoub Law Firm did not handle this case.