Definition of "accident" in Insurance Coverage Dispute Case

In Kolbuc v. ACE INA Insurance, 2007 ONCA 364 (CanLII), Kolbuc was a plasterer who became paralyzed after being bitten by a mosquito carrying the West Nile virus.  He attempted to claim coverage for his illness from his disability insurer, but his claim was denied.  The insurance company defined the cause of the illness was not caused by an “accident”.  According to his insurer’s descriptions, a disease is not an accident- a proposition which, standing alone, is correct and already addressed in the insurer’s policy.  Kolbec appealed against his insurer and claimed that a disease can be defined as an “accident” as long as it was caused by an external source and was unforeseen and or unpreventable. 

Issues
The main issue in Kolbuc’s case was what the definition of “accident” was in a case where the line between ‘natural’ and ‘external’ became greyed.  When Kolbuc sued, the appeal was initially denied.  The trial judged relied upon another court decision in the case of Wang. v. Metropolitan Life Insurance Co., 2004 CanLII 21269 (ON CA) which held that the death of an expectant mother resulting from an amniotic fluid embolism during childbirth did not meet the definition of an “accident”.  The mother’s death was an incident caused naturally and internally, it was not an accident but a mere tragedy.  

Decision for Award
Kolbuc appealed again for coverage, and the Supreme Court (overruling the Court of Appeals) concluded that he was indeed entitled under the policy.  The Supreme Court’s reasoning was as follows:

[1] Kolbuc’s injuries were caused by an external force, [2] the said external force was not foreseeable, and [3] the paralysis resulted from the incident was not attributable to the insured in any way. 


Further, the Supreme Court was concerned that accident insurance policies would be transformed into comprehensive health policies if they covered diseases that were contracted ordinarily.  Instead of considering whether West Nile virus was introduced to Kolbuc by an external factor (in this case, a mosquito), the Supreme Court held that courts must consider the entire chain of events that led to the loss.  This would have eliminated any misunderstandings between the insurer and the insured in the first place and would be an important step in future legal disputes.

Comment
In the wake of the West Nile virus outbreak, courts have been obliged to consider the legal implications of pandemics and to find effective and fair ways to treat its victims.  One major conclusion they have made through Kolbuc’s case is that insurers must clarify the extent of their policies’ coverage and insureds must be able to provide the exact course of events which led them to their losses.  The key to legal disputes is mutual understanding.

Tips
Individuals are free to purchase health insurance for themselves against the risk of contracting a disease in a normal course of events.  However, this type of insurance often excludes the risks covered by accident insurance policies, such as illnesses contracted due to predictable circumstances or irresponsibility of the insured.  If you wish to be prepared for unpredictable situations, accident insurances are liable to provide coverage for your accidental injuries.

It is important to note that accident insurances can provide you coverage only if your losses have come from an accident, not in an event which was deliberate, foreseeable, or natural.

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