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Accidental Death Benefit Denied By National Union Fire Insurance Due To Language of Policy Exclusion

After Frederick Ervin drowned in the spring of 2014, his widow, filed a claim to collect death benefits under his accidental death insurance policy carried by his employer. Her claim was denied as was her administrative appeal. She then filed this ERISA lawsuit. In Ervin v. Nat’l Union Fire Ins. Co. of Pittsburgh, PA, a federal court in Maryland agreed with National that the widow was ineligible to collect benefits based on the specific language of the policy excluding coverage when the death “results directly or indirectly” from “sickness, disease, mental incapacity or bodily infirmity.”

Factual History

Mr. Ervin was out boating with a friend when he suddenly became ill. When he leaned over the side of the boat to vomit, he fell into the river and appeared immobile. His friend was able to get assistance and pulled Ervin from the water, but Ervin died shortly thereafter. Ervin’s widow and National agreed that Ervin suffered from heart disease, but disagreed about the influence the heart disease had over his death and Mrs. Ervin’s eligibility for accidental death benefits.

The initial autopsy report concluded that Ervin “died of Atherosclerotic Cardiovascular Disease complicated by drowning.” The opinion of the assistant medical examiner who conducted the autopsy was that Ervin had a heart attack prior to leaning over the side of the boat to throw up. The examiner also noted on the autopsy report that the cause of death was an “accident.”

In response to Widow Ervin’s claim for benefits, National ordered an independent review of the record by Dr. Baker, a forensic pathologist. Baker concluded that the heart attack came first which rendered Ervin unconscious. Although falling into the water was an accident, the heart attack was the catalyst that caused him to fall and it was “his underlying cardiac disease that started the unfortunate chain of events on 4/18/14 that led to his death.”

Federal District Court Analysis and Decision Denying Benefits

The court analyzed many similar court cases which had concluded that even if an illness is “a cause of a cause of death,” it does not preclude coverage under a standard accidental death policy. For example, in one case, accidental death benefits were paid when a driver had an epileptic seizure, ran into tree and suffered a fatal head injury. But, in that case, there was no exclusion written in the policy as was written in the National policy under which the Widow Ervin was trying to collect. In denying her benefit claim, the court concluded that by “applying the actual language contained in the Policy,” recvery was “excluded under Exclusion #2.”

In explaining its conclusion that Ervin’s widow was not entitled to benefits, the court recognized that if Mr. Ervin had experienced his heart attack on land, he might not have died. But, since the heart attack contributed to his death “in an immediate and significant manner,” and according to the medical examiner, it was “his underlying cardiac disease that started the unfortunate chain of events,” the specific exclusion language of the policy was “clearly applicable.”

This case was not handled by our office, but it may provide family member survivors guidance in their pursuit of compensation under the accidental death clause of an insurance policy. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.



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