Court Agrees with Accidental Death Claim Denial

The employer-sponsored benefit plan, in which Adolph Chiarino was a participant, excluded coverage for “any accidental losses caused by, contributed to by, or resulting from ‘a disease of the body,’ ” BNA reports. Chiarino had a 19-year history of diabetes with chronic renal failure before being involved in a car accident.   After the accident, Chiarino’s renal failure worsened and he died.   The death certificate listed the cause of death as renal disease due to diabetes that was contributed to by the accident, the court said.

Chiarino’s widow submitted a claim for accidental death benefits to plan administrator First UNUM Life Insurance Company.   UNUM denied the claim since renal failure substantially contributed to Chiarino’s death and is a disease of the body.   The court opinion said the doctor who signed the death certificate wrote a letter to First UNUM saying that the complications from the accident were unable to be stabilized due to Chiarino’s renal disease and that “if he had not had this accident, he probably would have lived several more years on maintenance hemodialysis,” according to BNA.

First UNUM reexamined its determination but again denied the claim.   Chiarino’s wife, individually, and on behalf of Adolph’s estate, filed a lawsuit challenging the denial of benefits under ERISA.

In its opinion the court said, “Since the medical evidence in this case, including the death certificate signed by Mr. Chiarino’s own doctor, indicated that his death was caused by or at least contributed to by his underlying pre-existing illness,” First UNUM’s decision was not unreasonable. The court said the doctor’s letter did not trigger coverage.

The case is Chiarino v. First UNUM Life Insurance Co., N.D.N.Y., No. 3:02-CV-0851, 9/30/05.