Pulmonary aspiration of vomit was recognized as an extraneous accident specified in the accident insurance policy
The following case is related to insurance payout conditions. A person insured by a contract of common accident insurance woke up late at night and vomited, then accidentally inhaled some of the vomit. The person was unable to eject the vomit and choked to death due to airflow obstruction. Insurance beneficiaries (legal heirs of the insured person) demanded the insurance company to pay the death benefit.
The Supreme Court construed that pulmonary aspiration of vomit fell under the category of "extraneous accidents" stated as the reason for insurance payment on general insurance clauses by the insurance company, and then sent the case back to the lower court for further consideration. (Judgment by the Supreme Court on April 16, 2013)
- Page 14 of Kinyu Syoji Hanrei No.1416
- Page 1 of Saibansho Jiho No.1578
Summary of the case
- Plaintiff / Appellant / Appellant of final appeal:
- X1, X2 and X3 (legal heirs)
- Defendant / Appellee / Appellee of final appeal:
- Y (casualty insurance company)
- Party concerned:
- A (accident insurance policyholder, insured person, ancestor of X1, X2 and X3)
A concluded a contract of general accident insurance (hereinafter called "the insurance contract") with Y, by which A is insured. General insurance clauses for the accident insurance (hereinafter called "the clauses") included the following.
- Y will pay the insurance benefit when the insured person has been injured from a "sudden", "contingent" and "extraneous" accident.
- Y will not pay the insurance benefit when the insured person has been damaged from brain disorder, disease or insanity.
- Y will pay the death insurance benefit if the insured person has been injured as mentioned in (1) and died as a direct result of it within 180 days from the date of the accident.
On December 24, 2008, A took several kinds of medicines prescribed for treatment of depression after eating and drinking. A took a nap for a while, then woke up around 2:00 a.m. on the next day, December 25 and vomited. Since A's airway reflex function was significantly weakened, A accidentally aspirated some of the vomit and was unable to eject it. A suffocated due to airway obstruction and was sent to hospital by ambulance. A was confirmed dead at 3:18 a.m. on the same day. The cause of death was suffocation due to pulmonary aspiration of vomit.
Side effects of the medicines A was taking included nausea* and vomiting. Some of the active ingredients interact with alcohol, produce central nervous depression, and deteriorate sensory perception, motor function, etc.
Significant deterioration of airway reflex function, which caused A's suffocation, was generated by central nervous depression and deterioration of sensory perception/motor function affected by the alcohol taken in A's body one or several hours before the pulmonary aspiration and by the above-mentioned medicines.
X1 and other legal heirs demanded Y to pay the insurance benefit. Y refused to pay it, alleging that A's suffocation was caused by the factor inside A's body and that the accident was not extraneous. Therefore, X1 and other legal heirs filed a suit against Y.
The first court of instance (reference precedent (1)) acknowledged the claim. The second court of instance (reference precedent (2)), however, overturned the original decision and dismissed the claim by X1 and other legal heirs on the grounds that "extraneous accidents" refer to accidents directly caused by external factors and do not include accidents caused by physical abnormality or disorder generated by medicine, alcohol, virus, bacteria or other substance which entered the body and that A's significant deterioration of airway reflex function which caused suffocation had been generated by central nervous depression as well as deterioration of sensory perception/motor function affected by alcohol/medicine, not directly by an external factor. Consequently, X1 and other legal heirs appealed to the Supreme Court.
- * a bout of vomiting in a sick condition
Reasons
The Supreme Court did not affirm the lower court decision because of the following reasons.
"The clauses specify that the insurance benefit will be paid when the insured person has been injured from a sudden;, contingent and extraneous accident. According to the context, it is construed that the extraneous accident refers to an accident caused by a factor outside the insured person's body (reference precedent (3)).
According to the clauses, the reason to pay the insurance benefit is an accident by which the insured person has been injured. Therefore, pulmonary aspiration of vomit which caused A's suffocation should be construed as such an accident, which is the reason to pay the insurance benefit. Pulmonary aspiration refers to a state where material swallowed has entered the lower airway instead of the esophagus. It is naturally associated with and caused by a factor outside the body. Therefore, it is reasonable to construe that pulmonary aspiration falls under the category of extraneous accidents stated in the clauses. This theory can be applied even if the substance which caused airway obstruction is stomach contents (vomit) of the insured person."
"The lower court decision by which A's suffocation was not categorized into injuries caused by extraneous accidents includes violation of law, which obviously influences the judgment. The aforesaid theory is reasonable. The lower court decision is unavoidable to be dismissed. The Supreme Court has decided to send the case back to the lower court for further consideration in order to judge whether or not the insurance benefit can be paid."
One of the judges added the following views.
"Pulmonary aspiration is usually caused by a substance taken directly from the mouth. In this case, the substance was the vomit. Probably because of this fact the lower court questioned if the accident should be regarded as an extraneous accident.
According to general medical dictionaries, however, pulmonary aspiration refers to the state where liquid or solid which should be swallowed in the esophagus via the oral cavity and pharynx has accidentally entered the lower airway in the process of swallowing. Pulmonary aspiration itself is an extraneous accident, regardless of the process of the object's entering into the oral cavity, i.e. whether or not the object was directly taken from the mouth, whether or not it was vomit (e.g. vomiting, hematemesis), whether or not it was intraoral object (e.g. oral hemorrhage, a broken piece of tooth)"
Explanation
The accident insurance is paid when the accident concerned was sudden, contingent and extraneous in its nature. The extraneous nature generally indicates that the accident was caused by a factor outside the body of the insured person (external factor). Accidents caused by internal factors such as disease are not included in the category of extraneous accidents. If so, the question is if it is good enough for an insurance claimant to verify that the accident was caused by an external factor, or if it is also necessary to verify that the accident was not caused by an internal factor.
The reference precedent (3) addressed a case where a person choked on a piece of rice cake and became out of consciousness due to hypoxic encephalopathy, requiring constant nursing care. The person was insured by a mutual aid contract, which has clauses similar to those of insurance. The clauses state that compensation will be paid when the person has been injured from a sudden, contingent and "extraneous accident. The disclaimer clause states that compensation will not be paid when the person has been damaged from disease or other internal factors. The court construed that it was good enough for the claimant to claim and verify a reasonable causal connection between the extraneous accident and the damage incurred by the recipient of mutual aid and that the claimant was not responsible for claiming and verifying that the damage had not been caused by disease of the recipient of mutual aid.
The judgment on this article was based on the reference precedent (3). The court construed that extraneous accidents also included suffocation caused by pulmonary aspiration of vomit, although the substance the person choked on was not directly taken from the mouth (unlike rice cake).
However, the case was sent back to the lower court, where it will be determined whether or not the exemption clause can be applied in this case. The insurance company will be exempt from the payment obligation if the accident is judged to have been caused by disease.
In the case of the reference precedent (3), a recipient of mutual aid suffered from Parkinson's disease. Since persons with Parkinson's disease sometimes experience symptoms of poor swallowing function, it was questioned whether or not the accident was caused by disease. The court judged that there was not enough evidence to prove that the accident had been caused by disease. This point is different from the judgment on this article, by which the case was sent back to the lower court.
In accident insurance cases, it is not always clear whether or not an accident should be construed to have been caused by an external factor or an internal factor. For example, in the case of reference precedent (4), an elderly person drowned to death in the bathtub and it was argued whether or not the accident should be construed to have been caused by an external factor. The Supreme Court quashed the original decision which denied extraneous nature of the accident, and construed that the accident had been caused by an external factor (For details, please refer to the description of the reference precedent (4)).
Reference precedents
- Judgment by the Kobe District Court on September 14, 2010 (the first instance)
(Page 21 of Kinyu Syoji Hanrei No.1416) - Judgment by the Osaka High Court on February 23, 2011 (lower court decision, appellate instance)
(Page 20 of Kinyu Syoji Hanrei No.1416) - Judgment by the Supreme Court on July 6, 2007
(Page 108 of Hanrei Jiho No.1984) - Judgment by the Osaka High Court on April 26, 2007
(Page 146 of Hanrei Jiho No.2006)
