How did the court determine the insurance company's denial of the 800,000 yuan accidental death claim, citing "sudden death," after a death occurred during overseas snorkeling?

The insured, Mr. Liu (pseudonym), purchased overseas travel insurance before his trip and unfortunately passed away during the trip. After failing to reach an agreement with the insurance company on the claim, Mr. Liu’s family members (his spouse, daughter, and parents, who are beneficiaries of the insurance contract involved) sued the insurance company in court, demanding payment of 800,000 yuan for accidental death benefits and 49,100 yuan for funeral and body repatriation costs within the scope of insurance claims. The Haidian Court, after review, ordered the insurance company to pay the beneficiaries 800,000 yuan for accidental death benefits and 49,100 yuan for body repatriation and funeral expenses.

The plaintiff’s family stated that Mr. Liu purchased an overseas travel insurance policy for himself in June 2023, with coverage from July 7 to 13, 2023, for a trip to Malé, Maldives. The policy specified “accidental death” benefits of 800,000 yuan, “death due to acute illness” benefits of 100,000 yuan, and included “body repatriation” services (limit of 2.5 million yuan, including 20,000 yuan for funeral expenses). The insurance contract defined “accidental injury” and “sudden acute illness.”

On July 11, 2023, Mr. Liu tragically died while swimming at a resort in the Maldives. Local police reports indicated the cause of death as “cardiopulmonary arrest,” with no obvious external injuries. The Maldives’ official death certificate recorded the direct cause of death as “sudden cardiac arrest.” After the incident, the insurance company arranged for body repatriation and cremation services, with the service providers providing detailed cost breakdowns.

Regarding the insurance claim, Mr. Liu’s family (his spouse, daughter, and parents) disputed the insurance company’s decision. The plaintiffs argued that Mr. Liu’s death was caused by drowning, supported by video footage before and after the incident, expert medical testimony, and academic literature, aiming to prove that the cause of death matched drowning characteristics. They claimed that the insurance company should pay the 800,000 yuan accidental death benefit and the actual costs of body repatriation totaling 49,100 yuan.

The defendant insurance company argued that, based on police records citing “cardiopulmonary arrest” and no external injuries, Mr. Liu’s death did not meet the definition of “accidental injury” in the insurance contract. Additionally, the insurance company’s appointed survey agency’s investigation report concluded that, considering the scene environment (shallow water, protective measures), Mr. Liu’s good swimming ability, the brief duration of the incident, and the official death certificate, his cause of death was more consistent with “sudden death due to acute illness” (such as cardiac arrest) rather than external accidental injury. Therefore, the company only agreed to pay the 100,000 yuan benefit for death due to acute illness under the additional coverage and believed that the body repatriation service payment also required an accidental injury cause, thus refused to pay the claimed accidental death benefits and related service costs. The insurance company informed the family of its decision via text message.

The court, after review, held that the key issue was whether Mr. Liu’s death qualified as an accidental death. According to the insurance terms, “accidental injury” refers to an external, sudden, unintended, and non-disease-related objective event that directly and solely causes bodily harm. Considering the evidence, Mr. Liu was in good health before the incident, with no medical records indicating relevant illnesses. His death while snorkeling in seawater was sudden and external, fitting the elements of “accidental injury”—non-intentional, sudden, external.

Regarding whether the cause of death involved “non-disease” factors, the insurance company claimed that Mr. Liu died from an acute illness (sudden death), but failed to provide effective evidence identifying the specific illness responsible. The Maldives’ reports and death certificate recorded “cardiopulmonary arrest” and “sudden cardiac arrest,” which are descriptions of the state at death, not specific causes. Sudden death can result from underlying diseases or non-disease-related external factors; it cannot be directly equated with death caused by disease. The existing evidence did not show that Mr. Liu had any underlying condition likely to cause death.

Regarding the burden of proof, the beneficiaries initially proved that the death was due to an accident and that Mr. Liu had no relevant medical history. Under these circumstances, the insurance company, which claimed the death was due to illness, bears the burden of proof. However, from the incident until the body was cremated, there was no evidence that the company requested an autopsy to determine the cause of death. Given the dispute over the cause and the beneficiaries’ initial proof, the insurance company failed to prove its defense that death was due to illness, and thus bears the adverse consequence of failing to provide evidence. Therefore, Mr. Liu’s death should be recognized as an “accidental injury” under the insurance contract.

In conclusion, the court ordered the insurance company to pay the beneficiaries 800,000 yuan for accidental death benefits and 49,100 yuan for body repatriation and funeral expenses within the scope of insurance coverage. After the ruling, the defendant insurance company appealed, but the second-instance court upheld the original judgment. The decision has now taken legal effect.

Judgment commentary:

This case is a typical personal insurance contract dispute, focusing on the precise definition of “accidental injury” in the insurance terms and the fair allocation of the burden of proof when facts are unclear.

First, the insurance contract terms should be strictly interpreted and applied. The core legal elements of “accidental injury”—external, sudden, unintended, and non-disease objective events—must be analyzed item by item in light of the specific facts. Especially regarding the “non-disease” dispute, it is clarified that “sudden death” itself is not a clear medical or legal diagnosis; it may be caused by underlying disease or other external factors. Therefore, a deeper investigation and evidence are required to determine the cause of the incident.

Second, the flexible application of the “who asserts, who proves” rule and the shifting of the burden of proof in civil litigation are emphasized. The beneficiaries have initially proved the occurrence of the accident and the absence of relevant medical history. When the insurer claims “death due to illness,” it bears the responsibility to provide evidence. If the cause of death can be further clarified through autopsy or other technical means, and the insurer neither requests an autopsy nor provides other valid evidence of specific illness, it bears the consequence of failing to prove its defense, consistent with fairness and procedural efficiency.

Finally, this case highlights the importance of protecting the legitimate rights and interests of insurance consumers (beneficiaries) and urges insurance companies to actively and prudently fulfill their investigation and verification obligations during claims processing. It serves as a warning that insurers should not simply deny claims based on vague conclusions like “sudden death” or non-disease-related death descriptions but should base their decisions on solid evidence and professional judgment, promoting integrity and regulation in the insurance market.

(Note: All persons mentioned are pseudonyms.)

Text by: Yuan Zhangrun, Haidian Court