Insurance company revisits declined claim

The accident

On 20 April 2015, Paula accidentally drove her car off the road and crashed into a fence. The trauma of the collision triggered a heart attack. Sadly, Paula passed away in hospital later that day.

Paula’s death was referred to the Coroner’s Office. The Coroner’s report found that Paula’s death was caused by “cardiac arrest as a result of and against a background of a motor vehicle crash”.

Paula had an accidental death policy with MAZ Insurance (MAZ). Paula’s husband, Wallace, made a claim under the policy.  MAZ declined the claim.

 

MAZ’s position

MAZ declined the claim because it believed the cause of Paula’s death was not covered by the policy. MAZ said there was no evidence that Paula died as a direct result of any accidental injuries. The policy defined accidental injuries as bodily injuries resulting from an accident caused by violent, external and visible means. MAZ found that Paula’s death was due to a heart attack rather than an accidental injury and there was no cover under the policy.

 

FSCL’s position

We received copies of MAZ’s decision and the Coroner’s report. We found that MAZ’s decision was inconsistent with the Coroner’s report.

The Coroner found, on the balance of probabilities, that Paula’s heart attack was caused by the car accident. The Coroner also found on the balance of probabilities that the car accident occurred before Paula suffered a heart attack. We considered that Paula’s car accident was violent, external and visible and that a heart attack in the circumstances was a bodily injury. We concluded that Paula’s death did fall within MAZ’s policy wording.

We asked MAZ to reconsider its decision. Maz then decided the claim should be accepted and paid $50,000 (the policy sum) to Paula’s estate.