Accidental Death Insurance: Determining Cause of Death
Accidental death policies are not to be confused with life insurance policies. By their terms, accidental death policies usually provide that the benefit will be paid out when death results from accidental, external means.
In determining whether a policy is payable, an issue often arises as to the exact cause of death and contributing factors. Further, exclusions in the policy often serve to allow the insurer to avoid payment.
Take, for example, the recent case of Downey v. Scotia Life Insurance Company, 2020 ABQB 638 CanLII). There, the insured died on a fishing trip. No autopsy was performed. The Coroner’s Report noted that the insured died by asphyxia due to drowning, and that the death was “accidental”. Other “significant conditions contributing to death” was “myocardial infarction”, with the explanation being that the insured “had a myocardial infarction and fell out of the boat.”
The court struggled with whether the terms of the policy covered the death. The court ultimately found that the death was “accidental” in that the medical condition did not cause the death. However, exclusionary provisions in the policy applied so as to exclude coverage. The exclusion clause provided that a death was NOT covered if the death was “in any manner or degree associated with or occasioned by” or “contributed to in any way whatsoever” by any naturally occurring condition, illness, disease or bodily or mental infirmity. Although broad, the exclusion clause was not so broad so as to be void. (Exclusion clauses may be voided if they are so broad so as to “nullify the coverage provided in the policy, and would be contrary to the reasonable expectations of an ordinary person.)
The court referred to numerous “accidental death” cases and the outcomes are sometimes difficult to reconcile. For example, coverage was found in the following cases:
- Insured fell from horse, developed pneumonia. Coverage applied. Death was due to fall. Pneumonia was a “sequela” of the accident;
- Insured suffered a seizure causing him to fall and lodge his head in a position causing asphyxiation;
- Insured suffering brain aneurysm causing fall into bathtub and drowning; and
- Insured suffering seizure while driving causing fatal collision.
Coverage was not found in the following examples:
- Insured suffering injury in car accident. Pre-existing condition of hemophilia was “mixed up in” the cause of death;
- Insured fell, died of heart attack caused by the fall; and
- Insured admitted to hospital for congestive heart problems, suffered fall at hospital requiring surgery, died from complications arising from surgery including congestive heart failure.
Accidental death claims can be complicated and raise difficult issues of factual determination: determining and framing the cause of death, and also issues of contractual interpretation: determining what is covered by the policy and what exclusions may apply.
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