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Life, Health & Disability Law
that term is defined” under the policy. Id. Plaintiff appealed the denial and during the administrative review, LINA retained a toxicologist who opined that an individual with a BAC above .18% has a loss of sense of care and caution, slower perception and reaction time, loss of coordination, and less ability to multi-task. He also opened that the decedent’s immunity to pain, loss of coordination and inability to perceive his dangerous situation were all impacted by his gross intoxication. Id. at 983. Based on these opinions and applying a reasonable person standard – i.e., would a reasonable person have viewed the resulting injury or death as a probable consequence highly likely to occur as a result of the conduct – LINA upheld the denial of benefits. LINA explained that “highly likely to occur” is interpreted as entailing a level of inevitability that is of a significant or large degree. Id. at 984
The father filed suit against LINA and the district court reversed the decision on cross motions filed by the parties. The court held that although the son engaged in extremely reckless behavior, a reasonable person would not have viewed his injury as substantially certain to occur as a result of his actions. Therefore, his death was accidental under the policy. Id. LINA appealed the decision.
Applying a de novo standard of review to the district court’s decision, the appellate court addressed how to define the word “accident.” Relying on its prior decision in Padfield v. AIG Life Insurance Co., 290 F.3d 1121 (9th Cir. 2002), in which it endorsed the framework for espoused in Wickman v. Northwestern National Insurance Co., 908 F.2d 1077 (1st Cir. 1990) to determine whether an event is an “accident,” the court noted that the analysis involves an overlapping subjective and objective inquiry. Id. It first examined the subjective portion of the inquiry but determined there was insufficient evidence in the record to determine the driver’s subjective expectation at the time of his death, although it noted he was wearing his seatbelt and had turned on his hazard lights. Id. at 985.
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FDCC ANNUAL INSIGHTS 2023