What Happened:
Terri Yates filed a claim for accidental death benefits under her employer’s group life insurance policy after her husband, Johnny Yates, died from a heroin overdose. His death occurred unexpectedly.

  1. Symetra’s Reason for Denial:
    Symetra, the insurance company, denied the claim by arguing that Johnny’s death wasn’t an “accident” because he voluntarily used heroin. They also believed his actions were intentional enough to trigger a policy exclusion for “intentionally self-inflicted injuries.”
  2. The Court’s Key Questions:
    • Was the Death Accidental?
      The court looked at whether Johnny’s overdose was truly unexpected. It used a test (known as the Wickman test) to decide if someone like Johnny would have expected the risk of dying from his actions.
    • Does the Exclusion Apply?
      The court also considered if the policy exclusion should cancel the benefits. It examined whether intentional use of illicit drugs means that death was the result of a self-inflicted injury.
  3. Court’s Findings:
    • Accidental Nature:
      The court concluded that there was no evidence Johnny intended to kill himself. His death was not something he expected to happen despite his risky behavior—it was an unintended overdose.
    • Policy Language Misinterpreted:
      The insurance policy defined an “accident” as a sudden and unforeseen event. The court held that Johnny’s death fit this definition because he did not expect to die from his drug use. The court rejected the insurance company’s argument that unforeseen equated to unforeseeable pointing out that harm is always foreseeable with risky behavior. However the purpose of Accidental Death insurance is in part intended to protect an insured from harm caused by his/her own careless or negligent acts.
    • Exclusion Not Applicable:
      The court ruled that the exclusion for “intentionally self-inflicted injuries” did not apply since there was no proof that Johnny believed that death was highly likely to result from his use of heroine particularly since he had a history of heroine use without incident.
  4. Result:
    The court sided with Terri Yates, ordering Symetra to pay the $50,000 accidental death benefit. This decision emphasizes that insurance should protect people against unforeseen accidents—even when risky behavior is involved.

This result mimics that obtained by Stennett & Casino in the 1996 case of Amendola v. A.I.G. Insurance Company involving a fatal heroin overdose which the insurance carrier argued was not covered under an accidental death insurance policy. Thirty years later insurance companies are making the same failed arguments.