District Court Finds Insurer Properly Denied Claim for AD&D Benefits Due To Decedent’s Intoxication Which Contributed To The Vehicle Accident

In Sherman v. Medmutual Life Ins. Co., No. 5:23CV2313, 2024 WL 4240137 (N.D. Ohio Sept. 19, 2024), Ohio Northern District Judge Christopher A. Boyko granted judgment in favor of Defendant MedMutual under an abuse of discretion standard, finding that the insurer reasonably concluded that intoxication was a significant condition contributing the decedent’s accident and death.

Plaintiff is the spouse and named beneficiary to basic and supplemental accidental death and dismemberment (“AD&D”) coverage which decedent obtained as a benefit of his employment. On the night of November 28, 2020, decedent was driving a Suzuki ATV on a roadway with his wife as a passenger. He lost control and drove off the road and into a ditch. Both were ejected and the ATV flipped over and landed on top of decedent, causing serious injuries eventually resulting in his death. Decedent’s blood alcohol concentration level was 0.256 upon admission to the hospital, over three times the legal limit in the State of Ohio, which is 0.08. The death certificate notes “alcohol intoxication” as a significant condition contributing to death; and the traffic crash report describes both decedent and his wife as under the influence of alcohol at the time of the accident. MedMutual denied Plaintiff’s claim and upheld its decision on appeal each time citing to the intoxication limitation in the policy.

In articulating the standard of review, the Court noted that an administrator’s rational interpretation of a plan must be accepted, even in the face of an equally rational interpretation offered by the participants. Plaintiff argued that alcohol was not the actual cause of the fatal accident, but that while traveling on the side of the roadway, the ATV tires struck gravel and fishtailed. Decedent attempted to correct the ATV but was ultimately unsuccessful and lost control.

The Court noted that while Plaintiff was the only witness to the accident, her explanation for the accident was sent on her attorney’s letterhead and was not a sworn statement, nor did she provide any authenticated evidence of when the ATV was purchased or Decedent’s experience operating such vehicles. Moreover, the Traffic Crash Report did not mention gravel, even though the form has a box for conditions and surface in which “gravel” could have been selected. The Court reasoned that under the applicable deferential standard, and interpreting the limitation provision according to its “plain meaning in an ordinary and popular sense,” MedMutual’s denial of AD&D benefits was neither arbitrary nor capricious because the record contained evidence linking or connecting Decedent’s intoxication to his death.

If your insurer has denied or otherwise limited your life, AD&D or disability insurance claim, contact us for assistance.