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Court Overturns Denial of Paralyzed Workers Benefits

January 6, 2010
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Related Topics: Disabilities, Miscellaneous Legal Issues, Benefit Design and Communication, Latest News
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An Aetna Life Insurance Co. diving accident investigation was insufficient to deny a paralyzed man benefits under an employee health policy’s accidental death and personal loss provision, according to a federal appeals court ruling.

In James M. Capone v. Aetna Life Insurance Co., a three-judge panel of the Atlanta-based 11th U.S. Circuit Court of Appeals on Tuesday, January 5, overturned a district court finding that Aetna properly applied the health plan’s accidental means and alcohol exclusions, according to court records.

Capone worked for Dent Wizard International Inc., a unit of Cox Enterprises Inc., in 2004 when he attended an employee training program in the Bahamas. Cox self-funded most of its benefits, but those covering accidental death and personal loss were insured by Aetna, according to court records.

While in the Bahamas, Capone dove off an ocean dock, struck his head and suffered permanent quadriplegia. Aetna denied his claim, arguing he intentionally exposed himself to unnecessary risks. Based on a hospital toxicology report, the insurer also cited an exclusion regarding use of alcohol.

Capone then sued and the district court found in favor of Aetna’s claims decision.

However, the appeals court ruled Tuesday that Capone’s contention that an unexpected wave created shallowness that otherwise did not exist shifted the burden to Aetna to prove he was not entitled to benefits.

“Aetna failed to investigate the depth of the water at low tide, the depth of the water at high tide, and the tidal conditions at the time of the accident,” the appeals court ruled. “Aetna made no attempt to locate other guests [as witnesses] who might have been on the scene.”

The court also said Aetna did not present “sufficient evidence that suggests that the consumption of alcohol caused or contributed to the accident and resulting injury.”

The appeals court reversed the lower court’s ruling and remanded the case for further consideration. 

Filed by Roberto Ceniceros of Business Insurance, a sister publication of Workforce Management. To comment, e-mail editors@workforce.com.

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