Why an ERISA AD&D Claim Can Fail When a Stroke Precedes a Fatal Fall

In Tegu-Watkins v. Hartford Life & Accident Insurance Co., No. 8:24-cv-2722-CEH-AAS, 2026 WL 2883359 (M.D. Fla. Sept. 25, 2026), the United States District Court for the Middle District of Florida granted the insurer’s motion for summary judgment and affirmed the denial of accidental death and dismemberment (AD&D) benefits under ERISA. The decision turns on whether a death must be independent of illness to qualify for benefits, an issue that arises often in ERISA accidental death claims where a medical event precedes the fatal injury.

What happened to the decedent, and what benefits did Plaintiff seek under ERISA?

Plaintiff is the surviving spouse of the decedent, who was employed as a lead mechanic and covered under a group policy issued by Hartford that provided AD&D coverage. The decedent was in his dining room when he suffered a stroke, fell, and struck his head on the floor. He died three days later. The autopsy report listed the cause of death as a skull fracture with intracranial hemorrhage due to blunt impact to the head, identified the cerebrovascular accident as a contributory cause of death, and listed the manner of death as an accident resulting from a fall from standing height following an acute stroke. The death certificate identified the same cause of death and listed the cerebrovascular accident as a significant condition contributing to death but not resulting in the underlying cause. Plaintiff sought the basic death benefit under the AD&D policy and brought claims under ERISA § 502(a)(1)(B) to recover benefits and under ERISA § 502(a)(3) for breach of fiduciary duty.

Why did Hartford deny the AD&D claim?

Hartford denied the claim and upheld the denial on appeal, determining that the death was not covered because it was not independent of an illness. The policy pays a benefit when a covered person dies as the result of a covered injury sustained in an accident, and defines injury as bodily damage or harm that must be independent of illness or any other cause. Hartford concluded that because the stroke was a contributory cause of death, the injury was not independent of an illness and the death did not constitute a covered injury under the policy. On appeal, Plaintiff submitted medical records to show that the decedent had not been diagnosed with conditions related to strokes, but Hartford maintained that the fall followed an acute stroke and that the death was therefore not the result of an injury independent of illness.

How did the court apply ERISA’s standard of review?

The court applied the Eleventh Circuit’s multi-step framework and began with de novo review to determine whether Hartford’s decision was wrong. Because it concluded the denial was not wrong at that first step, the court ended the inquiry without proceeding to the deferential arbitrary and capricious analysis. The court also explained that in an ERISA benefits case it sits more like an appellate judge than a trial judge, and that review is limited to the material available to the administrator when it made its decision.

Did the “substantially contributed” test apply, and must the death be independent of illness?

Plaintiff argued that Hartford should have applied the substantially contributed test from Dixon v. Life Insurance Co. of North America and had to substantiate the denial with evidence of a preexisting condition that substantially contributed to the death. The court distinguished Dixon and the related authorities Plaintiff cited, explaining that those cases involved a known preexisting condition, predisposition, or susceptibility, while here there was no preexisting condition at issue and Hartford did not deny the claim on that basis. The court framed the question as whether the stroke substantially contributed to the death, not whether the decedent had a preexisting condition. The court also rejected Plaintiff’s argument that the independent of illness requirement did not apply to basic death benefit claims. Reading the policy as a whole, the court held that the benefits provision and the definition of injury must be read conjunctively, so that a basic death benefit claim requires that the person die as a result of bodily harm independent of illness. The court further distinguished Bradshaw v. Reliance Standard Life Insurance Co., noting that Bradshaw concerned a preexisting condition exclusion, while this policy contained no such exclusion for AD&D benefits.

Who bore the burden of proof, and did Plaintiff meet it?

The court held that Plaintiff bore the burden of proving entitlement to benefits, and that the burden did not shift to Hartford because the denial was not based on a policy exclusion. The definition of injury appears in the definitions section rather than the exclusions section, so the court treated the independent of illness requirement as part of Plaintiff’s burden rather than an exclusion Hartford had to prove. The court found that the death certificate and autopsy report, which Plaintiff identified as her best evidence, did not establish that the death was the direct result of an accident and independent of illness. To the contrary, the autopsy report indicated that the stroke played a contributory role in the death. Because Plaintiff did not meet her burden, the court held that Hartford’s denial was not wrong under de novo review and granted Hartford summary judgment on the benefits claim.

What happened to the ERISA breach of fiduciary duty claim?

The court held that Plaintiff abandoned her breach of fiduciary duty claim under ERISA § 502(a)(3) because she did not raise it in her motion for summary judgment, her response to Hartford’s motion, or her reply. The court granted Hartford summary judgment on that claim as well, directed entry of judgment in Hartford’s favor, and closed the case.