In Werbianskyj v. Zurich American Insurance Co., Case No.: 3:15-cv-104 (N.D. Ind. August 1, 2016), the United States District Court for the Northern District of Indiana upheld an insurer's denial of accidental death benefits for a claim involving the death of a maintenance man in a case brought by his wife. The decedent was replacing a light fixture in the course and scope of his employment when he was electrocuted and died. A subsequent investigation showed bare wires. An autopsy confirmed an accidental electrocution as the cause of death; however, the autopsy also revealed THC, the active ingredient in marijuana, in the decedent's blood and urine.
The insurer issued two group accident policies to the decedent's employer. There were essentially two policy provisions relevant to the case: (1) the insuring agreement, which required that an insured suffer "a loss of life as a result of a Covered Injury", defined in relevant part as "an injury directly caused by accidental means which is independent of all other causes..."; and (2) the Drug and Alcohol exclusion, which barred coverage if a "Covered Loss" was "caused by, contributed to, or result[ed] from..."being under the influence of any...narcotic...unless such...narcotic...was prescribed by a physician and taken in accordance with the prescribed dosage..." Also of crucial importance, the subject policies contained discretionary clauses that afforded the insurer deferential authority.
The insurer referred the claim to a physician for a medical records review. The doctor, citing to numerous studies of drivers involved in car accidents under the influence of THC, opined that "to a reasonable degree of medical and forensic certainty" that the THC levels were sufficient to "significantly impair the deceased and contribute to the events that led to his electrocution." The insurer then referred additional reports to the doctor for a subsequent review. The doctor stated that the high levels of THC in the decedent's system would impair his attention to detail, judgment and concentration. The doctor further concluded, essentially, that the accident would not have occurred involving a person not under the influence of THC. On the basis of the doctor's opinions, the insurer denied the claim for benefits asserting that: (1) the decedent's death did not result from accidental bodily injury within the meaning of the policies; and (2) the Drug and Alcohol exclusions barred coverage.
The Court, applying an arbitrary and capricious standard of review due to the policy language, upheld the insurer's decision. The Court noted the importance of the policy's insuring agreement language requiring that the death be caused by an accident "which is independent of all other causes." Further, there was sufficient evidence in the Administrative Record that THC contributed to the accident that caused the decedent's death. Thus, the court held the Plaintiff could not meet her burden to show that the insurer's decision was arbitrary or capricious.