Criminal-Act exclusion does not apply without sufficient causal nexus

We get many calls involving claims denied based upon exclusions for losses or disabilities resulting from certain excluded conditions. Common excluded losses are those resulting from pre-existing conditions, suicide or attempted suicide, acts of war, or criminal acts.

In a recent case out of Kansas, a federal court was faced with determining whether there was a sufficient causal nexus to deny a claim based upon a criminal-act exclusion. The Plaintiff in this case sought accidental death benefits against an ERISA plan administered by Sun Life. The Plaintiff’s decedent was killed in an auto accident when another vehicle improperly crossed the center line. The Plaintiff’s decedent was not at fault in the accident in any way but was driving on a suspended license. Sun Life denied the claim based upon an exclusion for losses resulting from a “…criminal act”.

There was no question that, in Kansas, driving on a suspended license is a criminal act. However, the court found that even though the decedent may have been guilty of a criminal act Sun Life still abused its discretion since that criminal act did not sufficiently contribute to the death so as to invoke the exclusion.

Sun Life argued its position using a test commonly used to determine actual causation. According to Sun Life, “but for” the fact that the decedent was driving at all when she should not have been that she would not have died.

As the court explained, the criminal-act exclusion would apply only if the decedent’s death was “due to or resulted from” her criminal act. A review of the accident report revealed that the decedent was free of fault in the crash that caused her death. Moreover, the status of her driver’s license did not increase the risk that she would die in an accident.

Sun Life defended its decision arguing that “but for [decedent’s] criminal act of driving while suspended, [she] might not have been on the highway when the westbound vehicle crossed the center line; but for her position on the highway when the westbound vehicle crossed the center line, the westbound vehicle would not have collided with [decedent’s] car; but for the collision, [decedent] would not have suffered injuries; and but for her injuries, [decedent] would not have died.”

The court found that, Tenth Circuit precedent required a more direct causal relationship to trigger the policy exclusion.

After reviewing the relevant case law, it became clear that the Tenth Circuit has foreclosed the use of “but for” causation to link otherwise insurable harms with ERISA-plan exclusion triggers.

Ultimately, Sun Life was found to have abused its discretion for its “legally erroneous” plan interpretation.

Leave a comment or ask us a question

Questions About Hiring Us

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Sachem C.

The best part about the experience working with Dell & Schaefer was that my attorney was upfront, honest, and transparent. He did not try to be a salesman and make promises about a case outcome. He was extremely direct about the way that things work and what he thought he was able to do for me. I valued this, because it is extremely rare to receive cut and dried information like this.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us