9th Circuit Requires That Any Illness or Infirmity Causing or Contributing to Injury For Purposes of Accidental Death and Dismemberment Benefits Had to be a Substantial Cause of the Loss to Avoid Coverage

On Behalf of | May 8, 2019 | Injuries

In Dowdy v. Metro. Life Ins. Co., 890 F.3d 802 (9th Cir. 2018), the insured sought benefits under an accidental death and dismemberment policy for an amputation of his leg resulting from a car accident. The leg was seriously injured as a result of the accident and was then later amputated. The policy provided that a covered loss was a loss that was a direct result of an accidental injury, independent of other causes. In deciding to deny the claim, Met Life relied upon a surgical report stating that due to comorbidities, as well as non-healing wounds and osteomyelitis, the patient had elected to undergo an amputation of the leg. Based upon the surgical report, Met Life concluded that the amputation was contributed to and complicated by the insured’s diabetes and that, under the terms of the policy, a loss caused or contributed to by an illness or treatment for that illness was excluded from payment.

The 9th Circuit Court of Appeals found in favor of the insured, concluding that the insured’s diabetes was not identified as a substantial contributor to the ultimate loss. The Court found that a substantial factor for purposes of the policy provision restricting coverage to direct and sole causes of injury, the preexisting condition had to be more than merely a contributing factor. On the record, the doctor’s surgical report identified a host of contributing factors, as well as faulting both comorbidities and the type of injury for the amputation. The Court found that there was coverage for the injury unless the preexisting disease is substantially contributed to the injury. The evidence established that while diabetes was a complicating factor, it was not identified as a substantial contributor to the ultimate loss and therefore the coverage denial was not supported. Met Life could not meet its burden of showing that the diabetes was substantially caused or had substantially contributed to the loss.