Death Cause not Necessarily Accident Under Plan Terms

In its opinion the court noted that some appellate circuits have interpreted a plan’s requirement that an accident result “directly and independently of all other causes” strictly, while other circuits adopted a “middle ground” test under which a pre-existing illness or disease negates the accident determination only if it “substantially contributed to the disability or loss.” However, the court found that, under either method of determination, Cheryl Pedersen’s death from entanglement in a home hospital bed was not an accident under the terms of her group life insurance policy.

Under the stricter requirement, a medical examiner’s testimony that Pedersen’s dementia, anxiety, morbid obesity, and difficulty clearing her airway contributed to her getting entangled in the hospital bed proves her death was not an accident “directly and independently of all other causes,” the court said. Under the “middle ground” test, Pedersen’s death was not an accident under the plan’s terms as the medical examiner testified that, but for her pre-existing conditions, Pederson would not have died or suffered any significant injury as a result of entanglement in the hospital bed.

Due to her difficulty in keeping her airway clear, Pedersen – who was under the care of her brother and sister-in-law – slept in a recliner. At the suggestion of her physician, Pedersen’s family purchased a hospital bed for her.

The first night she slept in the bed, she died. Her sister-in-law discovered her the next morning with her feet entangled in the bed rails and signs she had struggled with the sheets. However, following a 911 operators instructions to try resuscitation, the family moved her body. The emergency response team’s report reviewed by medical examiners mentioned no signs of entanglement.

A medical examiner determined Pedersen’s death to be natural due to her inability to clear her airway. After Pedersen’s sister-in-law expressed concern that details of her death were not included in reports to examiners, the examiner changed the death determination to accident.

Pedersen’s sister-in-law, as beneficiary of her life insurance, submitted a claim for benefits to Union Labor Life Insurance Company. The administrator denied the claim, ruling the death was not accidental under the terms of the plan. Pedersen’s sister-in-law sued the administrator under the Employee Retirement Income Security Act (ERISA) for wrongful denial of benefits.

The court denied a motion for summary judgment by the plaintiff and granted summary judgment to the administrator.

The case is Pedersen v. Union Labor Life Insurance Co., E.D. Wis., No. 06-C-75, 11/29/06.