Opinion ID: 171456
Heading Depth: 1
Heading Rank: 9

Heading: Was Brad Kellogg's death caused by his purported seizure?

Text: The sole basis relied on by MetLife for denying Kellogg's claim for AD & D benefits was its conclusion that Brad Kellogg's physical illness, the seizure, was the cause of the crash. App. at 129. Applying a de novo standard of review, however, we conclude that the car crash not the seizurecaused the loss at issue, i.e., Brad Kellogg's death, and therefore the exclusionary clause of the policy does not apply. [1] We have long held that insurance policies are interpreted according to their plain meaning. See, e.g., Webb v. Allstate Life Ins. Co., 536 F.2d 336, 339 (10th Cir. 1976) (Terms of an insurance policy must be considered not in a technical but in a popular sense, and must be construed according to their plain, ordinary and accepted sense in the common speech of men....). [2] Furthermore, [i]nsurance contracts, because of the inequality of the bargaining position of the parties, are construed strictly against the insurer. Mutual of Omaha Ins. Co. v. Russell, 402 F.2d 339, 345 n. 19 (10th Cir.1968). These rules of construction apply equally to ERISA cases governed by federal common law. See Miller v. Monumental Life Ins. Co., 502 F.3d 1245, 1249 (10th Cir.2007) ([A]pplying federal common law, we determine that the proper inquiry is not what [the insurer] intended a term to signify; rather, we consider the common and ordinary meaning as a reasonable person in the position of the [plan] participant would have understood the words to mean.) (internal quotation marks and ellipsis omitted; third alteration in original); see also Jones v. Metro. Life Ins. Co., 385 F.3d 654, 664 (6th Cir.2004) ([F]ederal common lawfrom pre-Erie diversity cases to present day ERISA casesfocuses upon the expectations and intentions of the insured.). Likewise, the doctrine of contra proferentem, which requires us to construe all ambiguities against the drafter, applies here. See Miller, 502 F.3d at 1253 (adopting rule that contra proferentum applies to de novo review of ERISA plans). [3] The First Circuit dealt with facts very similar to the instant case in Vickers v. Boston Mutual Life Insurance Co., 135 F.3d 179 (1998) (applying ERISA). The insured suffered a heart attack while driving and died after crashing into a tree. See id. at 180. The accidental death policy excluded loss resulting from ... sickness, disease or bodily infirmity. Id. The death certificate listed the cause of death as [m]ultiple blunt force traumatic injuries secondary to motor vehicle accident precipitated by acute coronary insufficiency. Id. The insurance company argued that [t]he nexus between the heart attack and the bodily injuries suffered from the crash was immediate and should be viewed as one entire event even though the heart attack was not the physiological cause of the decedent's death[,] id. at 181-82, to which the court responded, [t]his is no answer when we are interpreting the word `cause' in a layman's insurance policy[,] id. at 182. The court explained that while the heart attack caused the crash, the crash was the sole cause of the death. Id. The court acknowledged that there would have been no crash (and therefore no loss) but for the insured's heart attack, but rejected the insurer's attempts to justify the exclusion through a complicated analysis of proximate cause. Id. at 181. The court instead emphasized the importance of viewing the policy as an ordinary policyholder would. Id. at 181-82. We followed this approach in Johnson v. Life Investors' Insurance Co., 98 Fed. Appx. 814 (10th Cir.2004) (unpublished opinion) (applying Utah law). While Johnson is not binding precedent, we find it persuasive and adopt its reasoning here. In that case, the insured (who suffered from muscular dystrophy and had a history of falls) fell down his basement stairs and broke his neck. Id. at 815. After being admitted to the hospital, he developed pneumonia and died. Id. According to his physician, the immediate cause of death was pneumonia due to, or as a consequence of, a cervical spine fracture, and the underlying cause of death [w]as myotonic dystrophy. Id. The policy at issue excluded coverage for any loss resulting from any injury caused or contributed to by, or as a consequence of ... any sickness or infirmity. Id. at 818 (internal quotation marks omitted) (emphasis in original). Strictly construing the language against the insurer, we determined that coverage is denied under this policy only where the illness causes the hospitalization and death ... and not where the illness causes an accident that causes the death.... Id. We noted that the insurer could have written the policy in such a way as to exclude accidents caused by illness (rather than only losses caused by illness). Id. We concluded, [s]ince it is undisputed that the immediate cause of [the insured]'s loss was a fall, it is irrelevant under the terms of this policy whether the fall was caused by his myopic dystrophy. Id. The Minnesota Supreme Court employed similar reasoning in Orman v. Prudential Insurance Co., 296 N.W.2d 380 (1980). In that case, the insured lost consciousness due to the bursting of a cerebral aneurysm and fell into the bathtub and drowned. Id. at 381. The policy excluded losses caused or contributed to by bodily infirmity or disease. Id. (internal ellipsis omitted). The court held for the insured. See id. at 383. Although the aneurysm was a disease under the policy, it did not cause the death and therefore was not excluded: It was a mere fortuity that the decedent stood over a bathtub full of water at the time the aneurysm burst and rendered her unconscious. In other words, the aneurysm may have contributed to the accident, but it did not contribute to the death. In such circumstances, the aneurysm is simply too remote to be deemed a direct or contributing cause of death. Id. at 382. Similarly, in National Life & Accident Insurance Co. v. Franklin, 506 S.W.2d 765, 766 (Tex.App.1974), the insured, who had a history of epileptic seizures, was found dead in the bathtub; the cause of death was accidental death by drowning. The insurance policy covered losses resulting directly and independently of all other causes, from bodily injuries effected solely through external, violent and accidental means, and contained an exclusionary clause prohibiting payment for losses that result[ ] from or [are] contributed to by any disease or mental infirmity. Id. The court assumed that even if the insured's epilepsy caused him to lose consciousness and fall into the bathtub, it did not cause death by drowning. Id. at 767. The court explained, [t]he epilepsy was merely a cause of a cause and was therefore too remote to bar recovery. Id. As these cases make clear, courts have long rejected attempts to preclude recovery on the basis that the accident would not have happened but for the insured's illness. As then-Judge Taft wrote in Manufacturers' Accident Indemnity Co. v. Dorgan, 58 F. 945, 954 (6th Cir.1893), [I]f the deceased suffered death by drowning, no matter what was the cause of his falling into the water, whether disease or a slipping, the drowning, in such case, would be the proximate and sole cause of the disability or death, unless it appeared that death would have been the result, even had there been no water at hand to fall into. The disease would be but the condition; the drowning would be the moving, sole, and proximate cause. See also Browning v. Equitable Life Assur. Soc., 94 Utah 532, 72 P.2d 1060, 1076 (Utah 1937) (A sick man may be the subject of an accident which would not have befallen him but for his sickness. One may meet his death by falling into a place of danger in a faint or in a fit of epilepsy. But an event has usually been held to be the result of an accident, not of disease.). [4] In its explanation of the insurance plan to its employees, Pfizer's SPD stated, If you die as a result of, and within 12 months after, an accident, your beneficiary will receive 100 percent of your AD & D coverage. App. at 68. The SPD advised that the Plan does not cover losses due to:... physical or mental illness, or diagnosis or treatment for the illness. Id. at 69. MetLife's Certificate of Insurance worded the exclusion slightly differently: We will not pay benefits under this section for any loss caused or contributed to by: [ ] physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity.... Id. at 293. Here, the loss (Brad Kellogg's death) was caused by a skull fracture resulting from the car accident, not by physical or mental illness. See id. at 109 (Letter from Stephen Morris, Merced County Sheriff's Department's Deputy Coroner). While the seizure may have been the cause of the crash, it was not the cause of Brad Kellogg's death. The Plan does not contain an exclusion for losses due to accidents that were caused by physical illness, but rather excludes only losses caused by physical illness. [5] Because there is no evidence that the seizure caused Brad Kellogg's death, MetLife's argument fails. The fact that the policy at issue here excludes losses that were caused or contributed to by physical illness does not change this analysis. A reasonable policyholder would understand this language to refer to causes contributing to the death, not to the accident. [6] See Orman, 296 N.W.2d at 382 (rejecting insurer's argument that caused or contributed to language excludes illnesses contributing to the accident but not the death); Franklin, 506 S.W.2d at 768 (The words `contributed to' do not serve to allow us to look back along the chain of causation to a remote cause or a cause of a cause.). Notably, this understanding of the policy's plain meaning is supported by Pfizer's own interpretation of MetLife's coverage: the SPD describes the plan as excluding only losses due to physical illness. See App. at 69. Having rejected the sole basis upon which MetLife grounded its denial of AD & D benefits, we must reverse the judgment of the district court and remand with directions to enter judgment in favor of Kellogg on the administrative record.