Yates v. Symetra: Defining “Accidental” in Life Insurance Claims

The recent decision in Yates v. Symetra Life Ins. Co. addressed the difference between accidental and intentional in the world of employee benefits and insurance claims. In a case that challenges the boundaries of what constitutes an “accident” under an ERISA-governed policy, the court’s ruling offers a fresh perspective on how policy language should be interpreted when lives—and benefits—hang in the balance.

Background of the Case

Terri M. Yates, an employee at Phelps County Bank, brought forward her claim for accidental death benefits under the bank’s group insurance policy issued by Symetra Life Insurance Company. The claim was initiated after the untimely death of her spouse, Johnny Yates, who was found deceased in circumstances indicating a heroin overdose. Initially, Symetra denied the claim based on a policy exclusion for “intentionally self-inflicted injuries,” arguing that Mr. Yates’ voluntary drug use negated the accidental nature of his death.

Unpacking the Facts

The administrative record painted a complex picture:

• Discovery and Evidence: Johnny Yates was found face-down on the floor of his bedroom with evidence suggesting a heroin overdose—such as the presence of a hypodermic needle and traces of substances in his blood. Toxicology reports confirmed the presence of heroin indicators alongside other narcotics.
• Policy Language: The group insurance policy defined “injury” as “accidental bodily injury which is a sudden and unforeseen event, definite as to time and place.” However, the denial letter from Symetra interpreted the requirement in the policy that the injury be “unforeseen as synomonous with “reasonably unforeseeable”. It also invoked an exclusion for intentionally self-inflicted injuries, arguing that because Mr. Yates intentionally used heroin knowing that it would cause harm.

Legal Analysis: What Does “Accidental” Really Mean?

At the heart of the case lies a crucial interpretation of policy language:

• Defining “Accident”: The court noted that while the policy defines “injury,” it does not provide a clear definition for terms such as “accident” or “unforeseen.” Rather than relying solely on Symetra’s interpretation—that a death could be disqualified if it was a foreseeable outcome—the court turned to the common, dictionary definition of “unforeseen,” meaning something not anticipated or expected.
• Applying the Wickman Test: To navigate this ambiguity, the court adopted the widely recognized Wickman test. This framework asks whether the decedent, or a similarly situated reasonable person, would have anticipated the injury as highly likely to occur as a result of the insured’s intentional conduct. In this case, there was no evidence suggesting that Mr. Yates expected his heroin use to result in a fatal overdose and in fact he apparently had used heroin previously without harmful effect.

The Court’s Ruling

Rejecting Symetra’s narrow interpretation, the court concluded:

• Death Was Accidental: The court rejected Symetra’s “reasonably foreseeable” definition of accidental and instead applied the “highly likely to occur” standard for determining if injuries occurring as a result of an insureds intentional conduct are covered as an accidental injury.
• Exclusion Misapplied: The court found that applying the “intentionally self-inflicted injury” exclusion to Mr. Yates’ case was a misapplication of the policy exclusion. It clarified that while risky behavior can be dangerous, not all such behaviors should automatically void an accidental death claim. The evidence supported the conclusion that Mr. Yates’ death was an accidental overdose rather than a deliberate act of self-harm. The absence of indicators for suicidal intent or any expressed desire to end his life played a critical role in this determination.

Ultimately, the judgment was entered in favor of Plaintiff Yates, awarding her a $50,000 accidental death benefit. This decision emphasizes that insurance should protect people against unforeseen accidents—even when risky behavior is involved—if there is no clear intent to self-harm.

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. Twenty-five years later insurance companies are making the same failed arguments.