Genal was the beneficiary of a $60,000 ERISA-governed accidental death insurance policy insuring his 74-year-old father, Gregory Genal, who died in 2010. The father had suffered from multiple sclerosis for approximately 25 years and used a wheelchair and a motorized scooter.
The father was found unresponsive in his backyard with his scooter nearby in the grass. The police and medical examiner concluded that he had fallen from the scooter. The medical examiner listed the cause of death as “Environmental Heat Exposure Complicating Multiple Sclerosis.”
Prudential denied Genal’s claim for accidental death benefits, concluding that the death was caused or contributed to by multiple sclerosis. Prudential relied on a policy provision stating that benefits were payable only for loss of life resulting directly from an accidental bodily injury and from no other cause, and on an exclusion for death resulting directly or indirectly from sickness.
Prudential’s medical director opined there were two events resulting in the death. The first was the fall from the scooter, but there was no evidence of physical trauma from the fall. Second, because the insured was unable to get up, he was exposed to two days of environmental heat. Prudential argued that “but for” the multiple sclerosis, the insured would have been able to remove himself from exposure to the elements after he fell.
The district court analyzed the claim under a two-part test previously adopted by the Fourth Circuit Court of Appeals.
First, a court is to determine whether there was a pre-existing disease, pre-disposition, or susceptibility to injury, and then whether it substantially contributed to the loss. See Adkins v. Reliance Standard Life Ins. Co., 917 F.2d 794 (4th Cir. 1990); Quesinberry v. Life Ins. Co. of N. Am., 987 F.2d 1017, 1028 (4th Cir. 1993) (when policy language limits coverage to losses caused by accident “directly and independently of all other causes,” a pre-existing condition which contributes to the loss does not bar recovery under an ERISA policy unless the pre-existing condition “substantially contributed to the disability or loss”).
Thus, a “direct and independent cause” does not mean that a plaintiff must prove that an accident was the sole cause of death. Rather, Genal only needed to establish that his father’s multiple sclerosis did not “substantially contribute” to the death. See Pegram v. Prudential Ins. Co., 2009 U.S. Dist. LEXIS 56672 (E.D. Va. 2009).
The court noted that the father’s death was triggered by his fall from the scooter, not by his multiple sclerosis. But for the fall, he would not have died. Therefore, the fall substantially contributed to his death. However, Prudential’s expert concluded that the insured died directly from heat exposure, and from no other cause. Had the insured fallen in his home, he would not have been subjected to heat exposure. Therefore, the multiple sclerosis did not substantially contribute to his death.
Second, the court concluded that the sickness exclusion was not applicable, because the insured’s pre-existing physical infirmity did not substantially contribute to his death. Specifically, after his fall from the scooter, the insured’s multiple sclerosis did not worsen or flare up to lead to his demise. Rather, it was the fall and heat exposure which directly contributed to his death.
Accordingly, the court held the exclusion did not apply and that Genal’s claim for accidental death benefits was payable.
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