In granting summary judgment to the defendants, the court said the language of the plan that said benefits would only be paid if an injury occurred “directly and independently of all other causes” was not ambiguous. In its opinion, the court cited other rulings in which the “directly and independently” language, “similar to those in many other accidental death or disability policies,” has been construed to “preclude recovery where disease or bodily infirmity is a concurrent proximate cause of death.”
When analyzing the evidence available to AIG when it made its decision to deny benefits, the court found it was not an abuse of discretion for it to determine that Michael W. Boldt’s death did not result “directly and independently of all other causes.” The evidence indicated that Boldt’s heart condition which precipitated his fall was a “concurrent proximate cause of death,” thereby barring coverage under the accidental death policy.
The autopsy report said Boldt “came to his death as a result of fresh water drowning. It is possible that the decedent lost consciousness previously to drowning as a result of cardiac arrhythmia, due to his enlarged heart (dilated cardiomyopathy).”
After Boldt’s truck rolled into a pond on his property, resulting in his death, his wife filed a claim with the Dow Chemical Company Voluntary Group Accident Insurance Plan. AIG was both the insurer and administrator of the plan, and denied his wife’s claim for benefits. AIG also subsequently denied her appeal.
His wife’s filed suit against the plan and AIG claiming, among other things, that AIG abused its discretion when making its decision due to a conflict of interest that exists when the insurer is also the plan administrator.
The case is Boldt v. The Dow Chemical Company Voluntary Group Accident Insurance Plan.