Accidental Death (AD&D) Claims: What Counts as an "Accident"

How AD&D differs from life insurance

Accidental death and dismemberment (AD&D) coverage is often sold alongside life insurance, especially through employers, and it is easy to assume the two pay together. They often do not. In Wickman, the beneficiary received the group life benefit, but the insurer denied the matching AD&D benefit because it concluded the death was not accidental. Wickman v. Northwestern National Insurance Co., 908 F.2d 1077 (1st Cir. 1990).

An AD&D claim has to clear two hurdles:

1. Coverage: the death must fit the policy’s definition of an accidental death (and usually happen within a set time after the injury; the Wickman policy required the loss to occur within 180 days of the accident).
2. Exclusions: no exclusion can apply.

The insurer’s denial letter should tell you which hurdle it relies on. Under the federal rule for employer plans, a denial must give the specific reasons and the specific plan provisions behind it. 29 C.F.R. § 2560.503-1(g)(1).

How policies define “accident”

Start with the policy. The Wickman policy defined an accident as “an unexpected, external, violent and sudden event,” and the court began its analysis with that wording. 908 F.2d 1077. Other common phrases include:

• “bodily injury caused by an accident”;
• “directly and independently of all other causes”;
• “accidental means.”

Each phrase invites a different argument. “Directly and independently of all other causes,” for example, is often the basis for denials where an illness or medical condition played a part (see exclusions below). Courts generally read policy terms by their plain meaning to an ordinary person, and Wickman noted the long-standing rule that ambiguous insurance terms are construed against the insurer. 908 F.2d 1077.

Accidental means versus accidental results

Older policies and older cases drew a line between an accidental result (an unexpected injury) and accidental means (an unexpected cause). Under the “means” approach, if the insured did something on purpose, the death could be treated as non-accidental even if the outcome was a surprise. The Supreme Court applied that distinction in 1934 in Landress v. Phoenix Mutual Life, over a well-known dissent by Justice Cardozo, as Wickman recounts. 908 F.2d 1077.

Wickman concluded that the better reasoning rejects the distinction and chose not to use it in the federal common law that governs ERISA plans. 908 F.2d 1077.

Other federal appeals courts have used Wickman since. The Sixth Circuit formally adopted its key holding, the “highly likely” question, for ERISA plans that do not define “accident.” Kovach v. Zurich American Ins. Co., 587 F.3d 323 (6th Cir. 2009). In the Eighth Circuit, a panel adopted Wickman, but the full court, rehearing the case, decided it on a narrower ground. King v. Hartford Life & Accident Ins. Co., 414 F.3d 994 (8th Cir. 2005) (en banc). We have not surveyed every circuit, so this page does not call Wickman a majority rule.

The Wickman test

The Wickman court laid out a step-by-step way to decide whether a death was “unexpected” and therefore accidental, judged from the insured’s point of view:

1. What did the insured actually expect? The starting point is the insured’s reasonable expectations. If the insured expected an injury similar in type or kind to what happened, it was not an accident.
2. Was that expectation reasonable? If the insured did not expect the injury, the fact-finder asks whether the assumptions behind that expectation were reasonable, giving the insured “a great deal of latitude” and considering the insured’s personal characteristics and experience. Unreasonable assumptions mean the injury is not treated as accidental.
3. If the evidence of actual expectation is unclear, the fact-finder asks an objective question: would a reasonable person, with background and characteristics similar to the insured, have viewed the injury as highly likely to occur as a result of the insured’s intentional conduct?

908 F.2d 1077. Applying that test, the court upheld the finding that Mr. Wickman’s fall from outside a bridge guardrail, while hanging on with one hand, was not an accident, because a reasonable person in his position would have expected serious injury.

The flip side matters to beneficiaries. Wickman recognized that people buy accident insurance precisely to protect against their own miscalculations and misjudgments, and it cited earlier decisions finding accidents where an experienced person misjudged a familiar risk. 908 F.2d 1077. The standard of review can decide how much that helps. In an Eleventh Circuit case from Florida, an experienced climber disappeared on a Pakistani peak after pressing on alone despite his climbing partner’s warnings; the court held that the insurer’s finding of no accident was reasonable under the deferential standard, while acknowledging a court deciding the question fresh might have ruled the other way (Goldfarb v. Reliance Standard Life Ins. Co., 106 F.4th 1100 (11th Cir. 2024)). The test is “highly likely,” not “possible” or “foreseeable.”

Common exclusions

AD&D policies commonly list exclusions. Wording differs from policy to policy, so the exact text controls. Typical categories:

• Suicide or intentionally self-inflicted injury. The Wickman policy excluded loss “directly or indirectly caused by” suicide or intentionally self-inflicted injury, “whether sane or insane,” and the court held that language barred benefits under either reading. 908 F.2d 1077. The Seventh Circuit read a similar exclusion to bar the AD&D rider for a death during autoerotic asphyxiation, treating the self-strangulation itself as the intended injury even though the insured expected to survive; the life benefit had been paid, and three judges would have reheard the case (Tran v. Minnesota Life Ins. Co., 922 F.3d 380 (7th Cir. 2019)). Other circuits have disagreed, so the governing circuit matters.
• Illness, disease or medical treatment. Many policies exclude losses caused or contributed to by sickness or disease, or by medical or surgical treatment. A heart attack while driving, or a fall caused by a stroke, is where these disputes arise. Causation can cut the other way, though. The Seventh Circuit rejected a denial where a young man tore his Achilles tendon playing basketball, had routine repair surgery, and died weeks later of a clot from the injured leg; the insurer’s “independently of all other causes” reading would have let it refuse almost any claim in which treatment followed an accident, and its only medical evidence was inconclusive (Prather v. Sun Life & Health Ins. Co., 843 F.3d 733 (7th Cir. 2016)).
• Intoxication. Some policies exclude deaths while the insured was legally intoxicated, often tied to a blood-alcohol level or to operating a vehicle. Wording such as “a contributing factor” still calls for proof about the event: in a Tennessee ATV rollover, a federal court reversed a denial resting on a 0.144 blood-alcohol level and elevated hydrocodone because the insurer’s own reviewer found no link to the death and nothing showed how the crash happened (Murchison v. Reliance Standard, W.D. Tenn. 2020). Others have no intoxication exclusion and instead argue that a drunk-driving death was not an “accident” at all.
• Drugs. Exclusions for drugs or narcotics often carve out drugs taken as prescribed by a physician. Overdose cases turn on that wording and on the toxicology.
• Other common exclusions: war, certain aviation, and injuries during the commission of a crime.

Drunk-driving deaths when the plan has no intoxication exclusion

Three federal appeals decisions show how fact-specific these cases are:

• Lennon (6th Cir. 2007). The insured had a blood-alcohol level of about 0.32 and, according to the record, drove the wrong way down part of a one-way avenue before hitting a wall. Reviewing under the deferential standard, the court let MetLife treat the death as not accidental. Lennon v. MetLife, 504 F.3d 617.
• Kovach (6th Cir. 2009). A motorcyclist with a blood-alcohol level of .148 ran a stop sign and lost a leg. The same circuit, applying Wickman, held that denying the claim was arbitrary and capricious. A collision was not “highly likely,” and treating every drunk-driving injury as non-accidental added an exclusion the plan did not contain. Kovach, 587 F.3d 323.
• King (8th Cir. 2005) (en banc). A motorcyclist with a blood-alcohol level of 0.19 died after leaving the road. The insurer defended its denial in court with a different standard than the one it had used to deny the claim. The court sent the claim back to the insurer to decide under the standard it now argued for. King, 414 F.3d 994.

The level of intoxication, the driving itself, the standard of review and the reasons the insurer gave at the time all mattered.

Building an AD&D claim or appeal

• Get the exact policy or plan language for the accident definition and every exclusion the insurer cites, plus the summary plan description for an employer plan.
• Collect the full death investigation: death certificate (and any amendments), autopsy, toxicology, police or accident reports, and witness statements. In Wickman, the death certificate itself was amended from suicide to a fall, which shows how much the underlying records matter.
• Address the insured’s expectations directly. Evidence of experience, routine, health and plans can bear on what the insured expected and whether it was reasonable.
• For employer coverage, use the appeal. Submit new evidence and request the relevant claim file within the plan’s appeal deadline. See Employer group life and ERISA for the deadlines and the standard a court will apply.

Be careful with AI-drafted appeals. Chatbots such as ChatGPT can turn out a polished appeal letter in seconds, but polish is not the same as substance. For employer coverage, the appeal is usually where the record gets built: courts reviewing an ERISA denial generally look at what was in front of the plan administrator, and some will not consider evidence that was never submitted (Perry v. Simplicity Engineering, 900 F.2d 963 (6th Cir. 1990); rules vary by circuit). A generic letter that skips the autopsy and toxicology findings, misreads the plan’s accident definition or exclusions, or leaves out the facts about what the insured expected may be the only chance to put that evidence in, and it may be hard to fix later.

AI tools can also get the law wrong with confidence. They have produced court decisions that do not exist and misstated what real ones hold. In Mata v. Avianca, Inc., a federal judge in New York sanctioned two lawyers and their firm for filing a brief that cited fake opinions generated by ChatGPT, while noting that using a reliable AI tool for help is not improper in itself (No. 22-cv-1461 (S.D.N.Y. June 22, 2023)). An insurer reviewing an appeal will check what it says against the policy and the records. Software can help organize documents or a timeline, but it is not a substitute for a lawyer who knows how AD&D denials are decided and how to build the record a court may later review.

Sources

• Wickman v. Northwestern National Insurance Co., 908 F.2d 1077 (1st Cir. 1990) (full opinion): law.justia.com.
• 29 C.F.R. § 2560.503-1, ERISA claims procedure (official eCFR): ecfr.gov.
• Prather v. Sun Life & Health Ins. Co., 843 F.3d 733 (7th Cir. 2016) (official opinion, Seventh Circuit): media.ca7.uscourts.gov.
• Tran v. Minnesota Life Ins. Co., 922 F.3d 380 (7th Cir. 2019) (full opinion): law.justia.com.
• Goldfarb v. Reliance Standard Life Ins. Co., 106 F.4th 1100 (11th Cir. 2024) (official opinion, Eleventh Circuit): media.ca11.uscourts.gov.
• Murchison v. Reliance Standard Life Ins. Co., No. 1:19-cv-01028-JDB-jay (W.D. Tenn. Apr. 23, 2020) (official text, GovInfo): govinfo.gov.
• Perry v. Simplicity Engineering, 900 F.2d 963 (6th Cir. 1990) (full opinion, CourtListener): courtlistener.com.
• Mata v. Avianca, Inc., No. 22-cv-1461 (S.D.N.Y. June 22, 2023), Opinion and Order on Sanctions (docket, CourtListener): courtlistener.com.

Not legal advice. This page summarizes general rules and the specific statutes cited. Your policy's wording, the state whose law applies, and whether the coverage came through an employer can all change the result. See the disclaimer and editorial policy.