CR370
Accidental Death

Policy covered “accidental death”; was the deceased’s death accidental?

The policy covered ‘accidental death’ which was defined in the policy as a “traumatic death caused solely by external, violent, unforeseeable and visible means, occurring independent of any other causes and within 14 days of such trauma proved to the satisfaction of the insurer.”

Two weeks after giving birth, the deceased was re-admitted to hospital with internal bleeding. She was discharged five days later. Four days after that she was admitted to hospital again and subsequently died.

According to the autopsy report, the cause of death was ‘perforated peptic ulcer’ and ‘deep vein thrombosis with complications thereof’. The medical practitioner’s report submitted with the claim form indicated that the cause of death was ‘pulmonary embolism’ and ‘patient developed DVT post c/section’.

The abridged death certificate stated that the cause of death was ‘under investigation’.

The insurer repudiated the claim on the basis that the evidence did not show that the deceased’s death was an ‘accidental death’ as contemplated by the policy.

The complainant, the deceased’s mother, then lodged a complaint with our office contending that the death was not due to natural causes but due to the hospital’s negligence and that the insurer had therefore erred in repudiating the claim.

It was explained to the complainant that as the claimant she bore the onus to prove that the death was an ‘accidental death’ as defined.

We pointed out that the complainant’s own speculation or opinion as to the cause of death did not assist her and furthermore that it did not follow from the fact that the autopsy report revealed ‘sepsis’ as being the cause of death that there was negligence on the part of the hospital concerned or otherwise that the death constituted an ‘accidental death’.

The complainant had also failed to provide the basis for her contention that the deceased was ‘not correctly monitored in the correct manner’ and that this was the cause of death.

Therefore based on the available evidence, it could not be said that the death was caused by external or unforeseeable means. As such the complainant had failed to discharge the onus of proof and we were therefore unable to uphold her complaint.

LS
April 2016