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The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that establishes minimum standards for health insurance benefits provided by employers. The health insurance benefits governed under ERISA may be used to pay for medical expenses related to car accidents.
When a car accident occurs, and an ERISA recipient is injured, a portion of the economic damages recovered through a personal injury claim would be used to compensate the recipient’s health insurance provider.
In rare cases, a car accident may be caused by a medical event, such as a heart attack, seizure or stroke. Someone who has pre-existing health conditions may be more likely than others to have medical events while driving. Crash-inducing medical events can be unpredictable, even in seemingly healthy people.
One ERISA recipient died in a car accident on his way to work after his car crossed the median, struck another car, and rolled over multiple times. The recipient suffered from several pre-existing health conditions, including heart disease and cardiac arrhythmia.
A medical review and autopsy revealed that a medical event likely led to the crash. Hypertensive heart disease was listed as his cause of death and on his death certificate. The deceased driver’s spouse and beneficiary filed for accident benefits.
Since the cause of death was not considered accidental, the recipient’s insurance company, Zurich American Insurance Co., ruled that it wasn’t covered under its insurance policy. The company based its decision on medical records, witness statements, medical examiner reports, and independent medical reviews. In addition, Zurich found that the deceased driver had THC in his system at the time of his death.
The deceased driver’s wife appealed Zurich’s decision, asserting that there was no evidence of a cardiac episode at the time of the crash. Moreover, a witness reportedly saw her husband breathing and profusely bleeding immediately after the crash.
A U.S. District Court judge ruled that the insurance company abused its discretion in denying the claim. The District Court’s ruling was reversed by the First Circuit. They asserted that pre-existing conditions only partly contributed to the crash. This decision was supported by the attorneys representing Zurich American Insurance Co.
Attorney Mark B. Morse called the First Circuit’s ruling a “strong indicator that the 1st Circuit defers to an administrator’s decision to the extreme.”
Attorney Morse also made it clear that not all ERISA plans include language excluding those with underlying medical conditions from receiving benefits. The court found that there was no hard evidence that the driver’s pre-existing condition is what led to his death.
This case is just one example of how insurance companies often take advantage of those who don’t know their rights. If you are dealing with an insurance provider following the death of a loved one, it’s critical that you consult with an attorney. Make sure they are experienced in ERISA cases and car accident claims.
Contact The Law Office of Mark B. Morse in Providence, Rhode Island to learn more. You can also call us (401) 831-0555
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