Who Bears the Burden of Proof in ERISA Life Insurance and Accidental Death Insurance Claims Can Be the Difference Between Winning and Losing Your Claim

Many employees in Chicago and throughout Illinois have some group life insurance and accidental death insurance provided by the employer.  When an untimely death occurs, and loved ones make a claim, they rarely think about the strategy to making such claims.  Combine the stress of a recent loss with the expedited regulatory time frames to claim and appeal life and accidental death insurance, and you have a process that makes it difficult for the beneficiaries to recover.  This is where a good ERISA life insurance and accidental death insurance attorney can help tremendously.  For example, few people really think about what it means for a death to be accidental, and how any exclusions in these policies work.  Typically, deaths are accidental if they were unintended or unexpected.  But most accidental death policies also state they exclude coverage if the death was caused by any illness or disease.  So what happens when your loved one dies from an accidental event, that interacts with some illness, disease, or allergy?  In most places, it’s a question of who bears the burden of proof, though not all lawyers know to press this issue with a court.

In Ellis v. USAble Life, No. 16-391, 2017 U.S. Dist. LEXIS 158636 (E.D.N.C. Sept. 27, 2017), Ellis was allergic to bee stings, and he died after being stung by a bee.  The death certificate listed as causes of death: “anoxic encephalopathy, cardiac arrest, anaphylactic response, and bee stings(s).”  The record did not specify how many bee stings Ellis suffered.  The policy excludes payment for death caused, directly or indirectly, by disease, infirmity, or infection.  The court acknowledged that where there is a pre-existing medical condition, the Fourth Circuit requires the pre-existing medical condition be a “substantial” cause of the death to exclude the accidental death from coverage.  The insurer argued anaphylaxis caused by the bee sting or stings was the cause of death, though that cause of death appears nowhere on the death certificate.  The court determined, because the insurer had discretionary authority, that it should win the claim.  But the court missed some important legal principles, and it does not appear the plaintiff’s lawyer pressed them, either.

In accidental death insurance claims, the claimant has the burden of proving the accidental death.  The burden then shifts to the insurer to prove an exclusion bars coverage.  This means the insurer in the above case had to produce evidence justifying its denial of the claim.  It appears the court switched these burdens, because the court acknowledged there was nothing in the death certificate stating anaphylaxis caused the death, but nevertheless stated the court was not convinced anaphylaxis was not a substantial cause of death, effectively transferring the burden to the plaintiff to disprove an exclusion, rather than placing the burden on the insurer to prove it.

If you have a claim for life insurance or accidental death insurance, call an ERISA life insurance and accidental death insurance lawyer right away.