Background
Thomas Kovach, covered under his wife’s employer AD&D plan, ran a stop sign on his motorcycle and collided with a car. His left leg was amputated below the knee. A blood test showed a BAC of .148%, and the plan’s dismemberment benefit was $125,000. Zurich denied the claim as not “accidental,” reasoning that injury was a reasonably foreseeable consequence of driving while intoxicated. It also relied on the plan’s exclusion for a “purposeful self-inflicted wound.” The plan excluded skydiving, bungee jumping and similar activities, but it had no exclusion for driving under the influence.
What the court held
Applying the deferential arbitrary-and-capricious standard, the court still reversed and ordered benefits paid. An ordinary person would call this collision an accident. The court distinguished Lennon v. MetLife, where the driver’s BAC was .321 and he was speeding the wrong way down a one-way street. It adopted the Wickman test: would a reasonable person in the insured’s position have viewed the injury as highly likely to occur? A merely “reasonably foreseeable” risk is not enough. Treating every drunk-driving injury as non-accidental amounted to an unwritten exclusion. The self-inflicted-wound exclusion did not apply either, because it confuses intentional actions with intentional results. The court’s advice to insurers was simple: write an express exclusion.
Why it matters
Kovach and Lennon together show how fact-specific intoxication denials are under ERISA. The degree of intoxication, how the crash happened and the exact plan wording all matter. Many group AD&D policies now include express alcohol or intoxicated-driving exclusions, so the first step is reading the current policy and certificate.
Read the opinion
Kovach v. Zurich American Ins. Co., 587 F.3d 323 (6th Cir. 2009) (CourtListener).
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.