TN 29 (05-01)

A. Policy — accidental death

1. Definition

An accidental death is a death: (1) resulting directly from bodily injuries, independent of all other causes, which were received solely by violent, external and accidental means; and (2) occurring within 3 months after the day on which the injuries were received.

2. Death Certificate

A death certificate generally indicates the cause of death; i.e., natural, accidental, homicide, or suicide. However, entries on the death certificate are not necessarily controlling. Evidence may establish that the cause of death was misclassified or that the circumstances of the particular case justify a finding that the death was accidental.

3. Issues and Resolutions

To decide whether the NH's death meets the statutory requirement of accidental death for purposes of excepting a mother/father, widow(er) or stepchild from the 9-month duration of relationship requirement, address and resolve the following issues. The issues and guidelines for their resolution are:

a. Issue #1

Did the deceased worker receive “bodily injury” through “violent, external, and accidental means”?

b. Resolution #1

A “bodily injury” occurs whenever the outside force or cause affects the body sufficiently to interfere with its normal function.

The cause of the bodily injury is:

1. “external” if it originated outside the body. An external force can include an injury suffered due to weather conditions or exertion.

   NOTE: By exertion we mean an activity that involves at least moderate effort for the average person. Routine activities, e.g., standing, do not constitute exertion for purposes of finding accidental death. Circumstances which more readily lend themselves to a favorable finding of accidental death include:

   • an unexpected heart attack occurs during moderate exertion;

   • an unforeseen event negates the voluntary nature of an activity, e.g., an exercise machine breaks down while exercising;

   • some unintended, unexpected, and unforeseen result occurs during exertion, e.g., a fall or slip while running; or

   • a crisis or sudden peril requires strenuous exertion.

2. “violent” if it is a force, however slight. The injury does not have to be inflicted by a blow or physical contact with something outside the body. NOTE: If the external force is determined to be exertion, the requirement of “violent” is met; and

3. “accidental” if the result is unforeseeable or unexpected.

c. Issue #2

Did the deceased lose his/her life as a direct result of the accidental bodily injury…independent of all other causes? That is, did the deceased die solely through violent, external, and accidental means?

d. Resolution #2

The resolution involves the concept of proximate or primary cause of death which is defined and analyzed below with guidelines for its application.

Definition:

The proximate or primary cause of death is either: (1) the direct cause of death; or (2) the initiating event in an unbroken chain of events, each causing the next, that leads to and ultimately causes death.

The pivotal question is: “But for this accidental injury, would the deceased have died at this particular time?

Analysis:

SSA must determine the cause of death in the context of the statutory requirements. Use of the term “accident” on the death certificate does not compel a finding of accidental death under the Act.

Where a pre-existing disease exists, SSA must decide which factor (the accidental injury or the pre-existing disease) was primarily responsible for causing death at the particular time that death occurred. A preexisting disease (or illness) does not, necessarily, preclude a finding that the accidental injury was the proximate cause of death.

In deciding whether the injury or the disease is the proximate cause of death, SSA must determine which is the more substantial contributing factor. The injury is the proximate cause of death if the medical evidence ”to a reasonable degree of certainty” shows that pre-existing conditions were under control at the time of the accident, even if they were active and capable of ultimately causing death. That is, the disease was not the direct or concurring cause of death.

Guidelines:

In conjunction with the above discussion, use the following guidelines for determining the proximate cause.

• If an accident causes or initiates a disease or infirmity from which death results, consider the accident to be the sole cause of the fatality.

• If the worker has a disease or infirmity, which is not, in and of itself, expected to endanger life, and an accident aggravates it to fatal proportions, consider the accident to be the sole cause of the fatality.

• If the worker had an active, progressive disease, which, in and of itself, could have caused death more than 9 months after the date of the marriage, and an accident aggravated it so that death resulted before 9 months of marriage elapsed, consider the accident to be the sole cause of the fatality.

• If the worker had an active progressive disease, which in and of itself, was expected to cause death before 9 months after the date of the marriage, and an accident aggravated it so that the death resulted at a particular time, do not consider the accident to be the sole cause of death.

• If the worker has an active progressive disease which, in and of itself, was expected to cause death before 9 months after the date of marriage and an accident initiates an unrelated disease or infirmity directly causing death, do not consider the accident to be the sole cause of death.

• If as a direct result of an accidental bodily injury the worker was unable to maintain his/her own life and therefore, placed on life support, consider the accidental injury, not the termination of the life support pursuant to a living will, to be the sole cause of death. A living will, also called an advance directive or advance medical directive, may be oral or written.

4. Credible Evidence Rule

If after obtaining all available evidence there is still doubt about whether the death was accidental, or more than one conclusion is possible, but there is:

• credible evidence to support a finding of accidental death; and

• no evidence of a sham marriage, exempt the widow(er) or stepchild from the 9-month duration of relationship requirement.

B. Procedure — accidental death

1. Development -- Exception

If the death certificate shows accidental death, assume that it was independent of other causes unless the death certificate clearly indicates that an ordinarily fatal illness was a contributing factor or unless other facts in the case indicate that death may not have been caused solely by the accident. In the absence of evidence to the contrary, assume that the worker was reasonably expected to live 9 months.

2. Development — All Other Cases

Thoroughly develop all cases involving allegations of accidental death not excepted in GN 00305.105B.1. while recognizing the sensitive nature of the development. This includes obtaining a death certificate in all cases, see GN 00305.105A.2., as well as hospital, doctor's, and, in the case of a homicide, police or coroner records and any other pertinent information and statements; e.g., a newspaper account of the death.

Of significant probative value, except in the case of a homicide, is a statement from the NH's primary care provider about the NH's condition prior to the accident, including any pre-existing disease (or illness), the status of the disease and its future impact on the NH's health. If the claimant alleges that the accident resulted from surgery, request the primary care provider assessment of the risk and the NH's likelihood of recovery.

3. Development -- Center for Disability

Contact the staff physicians in your RO's Center for Disability Programs if you need assistance with medical evidence or findings obtained in alleged accidental death cases. Limit your contacts to requests to:

• Translate unfamiliar medical jargon or terminology;

• Provide guidance about what assumptions the factfinder can draw from the medical evidence submitted; and

• Explain or clarify the content of a piece of evidence.

4. Development -- Special Focus

a. Suicide

In addition to the death certificate, obtain full information as to the worker's mental condition immediately before death. This includes eyewitness accounts, expert medical findings, and lay opinions based on factual observations.

Death by suicide is not accidental if the act of suicide was an intentional and voluntary act. Death by suicide is accidental only if at the time of death the deceased was so mentally impaired/ill as to be incapable of acting intentionally or voluntarily. The mere fact that an individual committed suicide does not automatically permit a finding of accidental death. To establish accidental death by suicide, the development must show that:

• the worker's reasoning facilities were so impaired that he/she did not realize that this act would naturally and probably result in death; or

• the worker was acting under a delusion which overpowered his/her understanding and will.

b. Homicide

In addition to the death certificate, obtain the police or coroner reports. Death by homicide is not accidental if it resulted from an assault or other gross provocation initiated by the deceased.

If there was action by the decedent that might be considered a provocation, the controlling factor is whether the deceased could have reasonably expected that the incident would result in death. Thus, even where an individual is an aggressor, if he/she could not reasonably anticipate bodily injury resulting in death at the hands of another, the death is accidental.

5. Documentation

Prepare an informal special determination in all awards and disallowances using the RPOC screen. Briefly describe the evidence requested, the evidence received, sequentially what events occurred, and your analysis that led you to accept or reject the allegation of accidental death.

C. Examples — accidental death

1. Example 1 — Preexisting Disease Which Is Under Control

The NH was anesthetized for dental surgery, had a stroke, and died 3 days later due to complications from the stroke. The NH's only preexisting illness was hypertension, but his blood pressure was normal before the anesthesia was administered. The NH's doctor confirmed that the NH's blood pressure was under control and she had recommended the NH for surgery.

Since the preexisting illness was under control, it can be determined that the injury (stroke) resulting from the external force (anesthesia) solely and directly caused death. This is true even if death would not have occurred except for the preexisting illness because the preexisting illness did not start the chain of events leading to death.

2. Example 2 — Preexisting Disease Which Is Not Under Control

A car crushed the NH's leg. The NH consented to leg surgery without identifying any medical problems. The NH developed an infection and died in the hospital four weeks later. The death certificate stated that a heart attack, complicated by a staph infection, caused death.

The NH's wife sued the hospital claiming unsanitary conditions caused the infection and death. An autopsy revealed severe arteriolosclerosis. The NH had been scheduled for a stress test due to chest pain complaints.

It can be determined that the NH had a pre-existing disease that was not under control and was capable of causing death at the time of the surgery. Therefore, the infection did not solely and directly cause death, nor did it initiate an unbroken chain of events that lead to death.

3. Example 3 — Credible Evidence Rule

The NH dies in a single-car crash. Emergency room records described massive injuries, but suggested possible heart complications.

An autopsy for the NH's insurance company reported non-fatal arrhythmia signs within 24 hours of the crash, but drew no correlation between the arrhythmia and the crash.

The NH's insurance carrier denied accidental death benefits to the widow. It strictly interpreted policy coverage as limited to deaths due directly to an accident, independent of all other causes; here, arrhythmia may have precipitated the accident.

The NH's doctor reported mild arrhythmia that was under control and being monitored closely. Fibrillation alone would not have caused death.

It cannot be conclusively determined in this case whether the NH's heart condition precipitated the accident. But documentation shows that the NH's heart condition was controlled and mild. Therefore, there is credible evidence to support a determination that the NH died solely from external, violent, and accidental means (the crash) resulting in injuries that directly and solely caused death.

4. Example 4 — Suicide As A Voluntary And Intentional Act

The NH's death certificate identified suicide by gunshot as the cause of death. The NH's widow stated that the NH was demoted at work, was distraught by their separation, had previously attempted suicide, was often absent from work, and had delusions.

However, the NH's psychiatrist concluded that the NH acted with intention and understood the probable consequences of his actions when he shot himself, although alcohol abuse may have been a factor.

Relying on the expert medical evidence, it can be determined that the NH's suicide was not accidental; that the NH's intentional shooting solely and directly caused his death.

5. Example 5 -- Exertion As An Outside Force

On a cool day, the NH, collapsed while lifting and moving heavy items and was hospitalized. A month later, he died without regaining consciousness. The cause of death was identified as a coma due to myocardial infarction.

The NH's doctor felt that an autopsy was not needed because, except for an old infarction, the NH had no history of cardiac illness. Recent blood tests were normal. The doctor reported that the NH was in good health and he would not have restricted the NH from engaging in strenuous labor.

It can be determined that bodily injury (infarction) solely and directly caused death. However, since the injury was wholly internal, an external force must be identified. Moderate exertion for an average person, such as heavy lifting by a healthy male, may be such an external fore. Since the NH had no preexisting illness or disease, the exertion may be considered the accidental, or unexpected, means causing the injury.