(CN) - An insurance company must award benefits to an Ohio man who lost his leg in a drunken motorcycle crash, the 6th Circuit ruled, because the incident falls within the broad definition of an "accident."
Thomas Kovach ran a stop sign and hit another vehicle while riding his motorcycle intoxicated in 2005. His injuries led to an amputation below the knee, and he and his wife filed a dismemberment claim for $125,000 with Zurich American Insurance Company.
Zurich America denied Kovach's claim, noting that he had a blood alcohol content of .148 percent, above Ohio's legal limit of .08 percent, and that he had tested positive for opiates and benzodiazepines. The insurer said his amputation was "a reasonably foreseeable consequence of driving while under the influence of alcohol and possibly drugs" and that it fell under the policy's "self-inflicted-wound exclusion."
A district court denied the couple's ERISA claim, and they appealed.
The dispute hinges on the definition of the word "accident" and how it's used in the couple's policy, Judge Ronald Gillman wrote for the Cincinnati-based appellate panel.
"We note at the outset that drunk driving is ill-advised, dangerous, and easily avoidable," Gillman said. "But ... so are many other activities that contribute to wrecks that a typical policyholder would consider 'accidental.'"
Gillman cited numerous studies finding that texting while driving, and even driving while tired, are just as likely or even more likely to cause crashes then drunk-driving. Also, the policy does not expressly list drunk-driving as an activity that would cancel out a policy, though it does list things like sky-diving and bungee-jumping, Gillman noted.
"Mr. Kovach's wreck clearly fits [the common definition of an accident] in that he did not 'expect' or 'intend' to hit another vehicle," Gillman wrote. "Rather, he 'carelessly' - or, more accurately, negligently - ran a stop sign, with the 'unfortunate result' that he was injured in the ensuing collision. A hypothetical witness placing a 911 call to report Mr. Kovach's crash would almost certainly have reported that he or she had just seen an accident."
The panel was equally unconvinced by the insurer's argument that Kovach's injuries weren't covered because they were "self-inflicted."
"Zurich's interpretation of the plan's provisions amounts to an additional, unwritten exclusion for all drunk-driving injuries, which is not permitted under even the most deferential standard of review," Gillman wrote.
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