After losing his leg due to a car accident, Mr. Dowdy filed a claim for benefits under a group coverage accidental death and dismemberment policy he received as a benefit of his employment. The group insurance policy, underwritten by Metropolitan Life Insurance Company, provided coverage, but only if the loss “was a direct result of the accidental injury, independent of other causes.”
The leg injuries Mr. Dowdy received in the car accident would not properly heal due to persistent infection problems. According to his surgeon, Mr. Dowdy’s diabetes was one of the reasons for healing difficulties and persistent infections. As a result, Mr. Dowdy’s left leg was amputated below the knee five months after the accident.
Initial Legal Proceedings
MetLife denied the claim, reasoning that the accident was not the direct and sole cause of the amputation because Mr. Dowdy’s diabetes contributed to the loss. After unsuccessfully appealing to MetLife, Mr. Dowdy sued the company in federal court. The trial court granted summary judgment to MetLife, dismissed Mr. Dowdy’s lawsuit, and he appealed the trial court’s decision.
Court of Appeals Decision
The Federal Appeals Court for the Ninth Circuit reversed the trial court ruling and held that Mr. Dowdy is entitled to his accidental death and dismemberment benefits. In making its determination, the Court made it clear that a pre-existing condition, such as diabetes in this case, does not prevent recovery unless the diabetes was a substantial contributing factor to the loss of Mr. Dowdy’s leg. (Dowdy v. Metropolitan Life Insurance Company, Docket No. 16-15824, decided May 16, 2018.)
In making this ruling, the Court relied upon state law and prior federal appeals court decisions to interpret the meaning of the “direct and sole clause” of Mr. Dowdy’s injury. Quoting one case, the Court stated:
“A pre-disposition or susceptibility to injury, whether it results from congenital weakness or from previous illness or injury, does not necessarily amount to a substantial contributing cause. A mere relationship of undetermined degree is not enough.”
Armed with this interpretation of direct and sole cause of accidental injury, the Court ruled that the evidence in the record was insufficient to establish that diabetes was a substantial contributing factor to the injuries Mr. Dowdy suffered.
This decision demonstrates that, even in a case governed by ERISA, courts look at policy language the way they always have: keeping in mind the reasonable expectations of the insured, along with the understanding that the language contained in most insurance policies is vague enough to require interpretation. When courts interpret the vague language of insurance policies, they typically will do so in a manner more favorable to the insured than to the insurance company. If MetLife is not paying your claim contact us.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack