Opinion ID: 78557
Heading Depth: 2
Heading Rank: 4

Heading: accidental means

Text: Generally, for an injury to result from accidental means, it must be the unexpected result of an unforeseen or unexpected act which was involuntarily and unintentionally done. Johnson v. Nat. Life, etc. Ins. Co., 92 Ga.App. 818, 90 S.E.2d 36, 37 (1955). Georgia law is clear that where an unusual or unexpected result occurs, by reason of the doing of an intentional act, with no mischance, slip or mishap occurring in the act, the ensuing injury is not caused by accidental means. See Laney, 757 F.2d at 1191. In other words, an accident is never present when a deliberate act is performed, unless some additional, unexpected, independent, and unforeseen happening occurs which produces or brings about the result of injury or death. See Jackson v. Nat'l Life & Accident Ins. Co., 130 Ga.App. 208, 202 S.E.2d 711, 712 (1973). However, when something unforeseen occurs in the doing of the act, the death or injury is held to be within the protection of policies insuring against death or injury from accident. See Commercial Cas. Ins. Co. v. Mathews, 57 Ga. App. 446, 195 S.E. 887, 892 (1938). Therefore, in order to recover under an accidental means standard, it is incumbent upon the plaintiff to show that in the carrying out of the act which preceded the injury something unforeseen, unexpected, or unusual occurred, causing the result to differ from the natural or probable consequence of his voluntary action. Thompson v. Prudential Ins. Co. of America, 84 Ga. App. 214, 66 S.E.2d 119, 122 (1951). Even if Capone's dive was intentional, if there was an intervening unexpected act, Capone would be entitled to recover under his policy. Other courts around the country have confronted the issue. While we recognize that these courts were not dealing with Georgia law, the law of accidental means is peculiar and we find these courts' reasoning persuasive. In U.S. Mut. Acc. Ass'n v. Barry, the Supreme Court held that although the plaintiff voluntarily jumped off a platform, he could still recover under an accidental means policy. 131 U.S. 100, 121, 9 S.Ct. 755, 762, 33 L.Ed. 60 (1889). The Court presumed that he intended to land safely like his companions before him and held that his resulting injury was unexpected and therefore constituted an accident under the policy. [9] See id. Barry reasoned that, if in the carrying out of the act that precedes the death or injury, although an intentional act, something unforeseen, unexpected, and unusual occurs which produces the death or injury, it is accidentally caused or results from accidental means. 131 U.S. at 109, 9 S.Ct. at 759. In Knight v. Metropolitan Life Ins. Co., the Arizona Supreme Court overturned a trial court's denial of recovery in the case of an experienced diver who dove off the Coolidge Dam, holding that his injury was covered under an accidental means policy because he hit the water differently than he planned. 103 Ariz. 100, 437 P.2d 416, 421 (1968). The Supreme Court of New Jersey allowed recovery under an accidental means policy after the insured voluntarily jumped off a boat in order to swim to shore. See Riker v. John Hancock Mut. Life Ins. Co., 129 N.J.L. 508, 30 A.2d 42, 43 (1943). Riker reasoned that even though the plaintiff's actions were intentional, he had intended to reach the nearby shore in safety. Id. at 44. In the instant case, Capone made the dive once without incident. Other individuals were diving or jumping in a contemporaneous fashion without incident. The evidence demonstrates that diving from the dock was a common practice. Prior occurrence of similar acts that did not result in injury is a strong indicator of changed conditions. As such, there was most likely some unforeseen or unintended condition or combination of circumstances that contributed to Capone's injury on that particular dive. Capone bears the burden of proving a prima facie case of entitlement to contractual benefits under the policy. See Con't Assurance Co. v. Rothell, 227 Ga. 258, 181 S.E.2d 283, 285 (1971). Capone contends that an unexpected wave created the shallowness that had not otherwise existed. If so, such a wave is a force external to Capone's body that caused or contributed to the unforeseen result. The burden then shifts to Aetna to prove that Capone is not entitled to benefits. See id. Aetna's position is that when Capone voluntarily dove into shallow water, the resulting injury was foreseeable, regardless of whether any change in circumstances occurred. As such, Aetna did not conduct a thorough investigation into the events preceding the injury. 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. [10] Aetna made no attempt to locate other guests who might have been on scene, which could have been done through hotel records. Capone showed that Aetna's estimate of the dock's height was clearly erroneous, yet the record does not reflect any additional action taken by Aetna to review their decision. Certainly an injury of this magnitude demands a full and complete investigation. Capone is precluded from bringing a breach of fiduciary duty claim in conjunction with a wrongful denial of benefits claim. Katz v. Comprehensive Plan of Group Ins., 197 F.3d 1084, 1088 (11th Cir. 1999). However, Aetna's responsibilities as a fiduciary illustrates the proper standard of investigation. 29 U.S.C. § 1104(a)(1), mandates that a fiduciary shall discharge his duties with respect to a plan solely in the interest of the participants and beneficiaries and . . . (B) with the care, skill, prudence, and diligence under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with such matters would use . . . . Consequently, Aetna had the responsibility to fully investigate Capone's claims before denying benefits. Aetna failed to adequately address the issues raised in Capone's appeal and the denial of benefits without a proper investigation was de novo wrong.