Opinion ID: 1097684
Heading Depth: 3
Heading Rank: 3

Heading: Bankers Life's Basis For Denial Of Crenshaw's Claim Remained The Same From First Denial Through Trial

Text: The innuendos in the majority opinion to the contrary notwithstanding, the day of trial was by no means the first time when Bankers Life denied the underlying policy claim by reason of the proposition that the amputation was caused solely by the preexisting arteriosclerotic changes within Crenshaw's right leg. The record reflects that Dr. McParland rendered his first opinion to Bankers Life on June 19, 1979, and that the opinion he gave at that time was precisely the same as he gave at trial. From the outset Bankers Life relied on the opinion of Dr. McParland and denied the claim solely on that basis. The first time Bankers Life communicated its decision to deny the claim to anyone acting on Crenshaw's behalf was the July 11, 1979 letter William Herzau wrote to Crenshaw's employer in Pascagoula. That letter stated in pertinent part that according to the medical information we have, it appears that Mr. Crenshaw's limb loss was because of severe arteriosclerotic changes in his distal blood vessels and subsequent ischemia and necrosis.... [7] This was Bankers Life's first denial of the claim and the reason given was the same as that tendered at trial. On April 8, 1980, Bankers Life wrote to Crenshaw again denying the claim. Again Bankers Life gave as its reason for denying the claim that according to all the medical information we have, it appears your limb loss was due to severe arteriosclerotic changes in the distal blood vessels and subsequent ischemia and necrosis... . In this letter Bankers Life adds This opinion was confirmed in the pathology report. [8] A third pre-suit denial of the claim occurred on June 27, 1980, when Herzau wrote to Crenshaw's attorney and again gave as his reason that the operative report indicates the instructing arteriosclerotic area most likely is in the femoral or popliteal artery area although no mention of the femoral or popliteal pulses is noted. At trial Bankers Life offered this same basis for its denial of Crenshaw's claim. See, for example, Mr. Lemersal at R. 869: Q. Why was Mr. Crenshaw's claim denied? A. Because in the opinion of our medical director, the cause of the loss was a disease process. Mr. Blessing at R. 978: Q. Now, what was the basis that you used in denying the claim? What did you tell Mrs. Doyle to tell Mr. Crenshaw? A. According to the medical findings which our doctor reviewed, the cause of the amputation was strictly due to a disease process and not due to any injury. Mr. Blessing at R. 909: Q. And the denial was based on Dr. McParland's report? A. Yes, it was. Mr. Herzau at R. 925: Q. If the alternator falling on the foot contributed to the injury ... if the alternator was considered to be an injury and contributed to a problem, I would guess it should be paid. This is what I was questioning. This is what I was trying to determine. Dr. McParland at R. 978: Q. Assuming there was trauma, from history, do you attribute any percentage of his loss to a trauma situation? A. Absolutely none. Q. And you conveyed your findings to the claims department at Bankers Life? A. I did. In short, Bankers Life's pre-suit position remained consistent from July 11, 1979 forward. That position expressed in three separate letters to Crenshaw or his representatives was substantially identical to the position taken by Bankers Life at trial. It is disingenuous to suggest that Bankers Life ever relied on any basis for denying the claim other than the view that the sole cause of the amputation was the pre-existing arteriosclerotic condition in Crenshaw's leg.