A participant covered under an employer-sponsored life insurance plan was killed when the jet ski he was operating hit an underwater rock, causing him to be flung into another rock and drown. A boating accident report listed excessive speed, alcohol use, and operator inattention as contributing factors. The report identified alcohol use as the primary cause of the accident, with operator inattention being the second. The participant’s blood alcohol content was 0.223.

The insurer, acting as plan administrator, denied the participant’s beneficiaries’ claim for benefits, citing two policy provisions. First, the plan administrator relied on an exclusion for intentionally self-inflicted injuries, reasoning that the participant’s voluntary ingestion of alcohol was an intentional act that contributed to the jet ski crash and the participant’s drowning. Second, the plan administrator denied the claim based on the policy’s definition of “covered accident” to only include unforeseeable events. The plan administrator maintained that it was foreseeable that operating a jet ski while intoxicated might result in death.

The court rejected outright the plan administrator’s denial of benefits based on the exclusion for intentionally self-inflicted injuries. In doing so, the court pointed out that there was nothing to suggest that the participant became intoxicated with an eye toward harming himself.

The court remanded the issue of whether the participant’s death came within the definition of “covered accident” for redetermination by the plan administrator. As a threshold matter, the court rejected a categorical approach to deaths occurring while a person was intoxicated, noting that statistics did not support such a per se finding of foreseeability of death. Moreover, the fact that the policy contained specific per se exclusions, but none for driving while intoxicated cut against finding an unwritten per se exclusion. In making its redetermination, the court ordered the plan administrator to evaluate all the facts and circumstances in determining whether the participant’s death was foreseeable, including the additional factors of operator inattention, excessive speed, and the likelihood that a sober operator would have detected the underwater rock. (Thies v. Life Ins. Co. of N. Am., WDKY August 17, 2011)