Opinion ID: 591205
Heading Depth: 1
Heading Rank: 3

Heading: Construing the Insurance Policy

Text: 24 The issue we confront here, whether a heart attack occurring after exertion falls within the terms of an accident insurance policy, has led to contrary results in different jurisdictions. See generally Kristine C. Karnezis, Annotation, Heart Attack Following Exertion or Exercise as Within Terms of Accident Provision of Insurance Policy, 1 A.L.R.4th 1319, § 5 (1980 & Supp.1991). Thus, there is an absence of any uniform or consistent body of law upon which we can rely. Our task, however, is to determine how the Utah courts would decide the question. 25 Under the terms of the accident insurance policy in the instant case, the claimant must meet three conditions: (1) there must have been a bodily injury, (2) the injury must have been accidental, and (3) the death must have resulted from the injury directly and independently of all other causes. R., Doc. 42. We consider each condition in turn. 26
27 We first consider whether a bodily injury occurred. Mr. Winchester suffered no external violence as evidenced by a wound or abrasion. The appellant contends instead that the heart failure itself constitutes the bodily injury. Thus, the question is whether, under Utah law, heart failure by itself constitutes a bodily injury as that term is used in an accidental insurance policy. 28 This Circuit construed Utah law in a similar context in Wright v. American Home Assurance Co., 488 F.2d 361 (10th Cir.1973). In Wright, the plaintiff sought to recover on an accidental death policy that provided benefits if the death resulted directly and independently of all other causes and effected solely through an accidental bodily injury. Id. at 364. Like Mr. Winchester, the plaintiff's decedent in Wright had possibly died of a heart attack. We stated that [i]n common usage, 'bodily injury' designates an injury caused by external violence such as a cut, a bruise or a wound. Id. Without evidence of such an injury, we held that the insurance company was entitled to judgment as a matter of law. Id. 29 Pursuant to our holding in Wright, a bodily injury under Utah law implies some sort of external violence without which the injury would not have occurred. Compare, e.g., Hoffman, 669 P.2d at 414 (decedent shot by police; recovery permitted) and Hardy v. Beneficial Life Ins. Co., 787 P.2d 1, 2 (Utah App.1990), cert. denied, 795 P.2d 1138 (Utah 1990) (decedent ingested drug overdose; recovery permitted) with Elton, 516 P.2d at 169 (decedent suffered heart failure caused by arteriosclerosis aggravated by stress but unaccompanied by any external violence or physical impact; recovery denied). The Utah Supreme Court in Elton listed a number of occurrences that it described as within the common usage of the term accidental bodily injury, including a sudden blow, or an airplane crash, or a falling brick on one's head, or a fall in the bathtub, or a slip on an indiscernible slick of ice, or a tumble from a haystack, or a misguided dart in the eye, or a hand in the wringer. 516 P.2d at 174. Notably, each of these accidents also involves a physical impact to the victim. 30 The broad reading that the appellant would give to bodily injury, that heart failure by itself is a bodily injury, would essentially read that term out of the policy altogether. Death, being a physical phenomenon, will always be caused by some broad concept of bodily injury, such as heart attack, stroke, or internal organ failure. If the phrase bodily injury were given such a broad interpretation in triggering death benefits, the phrase would really be superfluous, because death always and necessarily entails such bodily injury. In such a case, an accidental death policy would be little different from a life insurance policy, save for any individual exclusions contained in each. See Elton, 516 P.2d at 172. Typically, an accidental death policy is available for considerably lower premiums than a life insurance policy, and we should be chary about fundamentally remaking a policy to cover situations not intended actuarially. 31 In the instant case, Mrs. Winchester presented no evidence of external violence or physical impact. Therefore, Mr. Winchester's heart failure by itself would not indicate that he suffered a bodily injury within the meaning of the insurance policy. This failure to meet the bodily injury requirement provides a first basis for affirming the district court's summary judgment in favor of Prudential. 32 The fact that we must review Prudential's interpretation under an arbitrary and capricious standard provides a second basis for affirming the district court. At worst, Utah law is ambiguous as to whether Mr. Winchester's heart failure constituted a bodily injury. Given the Tenth Circuit's previous construction of Utah law in Wright, Prudential's interpretation is certainly defensible and cannot be characterized as arbitrary and capricious. Thus, deference must be accorded to the plan administrator in its interpretation of the plan given the fact that the ERISA plan provides that the insurance company has the exclusive right to interpret the provisions of the Plan, [and] its decision is conclusive and binding. R., Doc. 42 (emphasis added); see Sandoval, 967 F.2d at 380.B. Accidental 33 The courts have divided over the question whether accidental in the context of an accident insurance policy means accidental means or accidental results. See generally Senkier v. Hartford Life & Acc. Ins. Co., 948 F.2d 1050, 1052-53 (7th Cir.1991); John D. Ingram & Lynne R. Ostfeld, The Distinction Between Accidental Means and Accidental Results in Accidental Death Insurance, 12 Fla.St.U.L.Rev. 1 (1984). Under the stricter accidental means approach, the activity or occurrence that led to the injury must have been accidental; thus, if a decedent engaged in the fatal activity intentionally, recovery would be barred. On the other hand, under the less strict accidental result approach, if death was not a reasonably foreseeable result of the activity in question, recovery is permitted despite the decedent's engaging in the activity intentionally. 34 The Utah courts appear to have wavered somewhat as to which approach to adopt. In Thompson v. American Casualty Co., 20 Utah 2d 418, 439 P.2d 276, 277-78 (1968), the Utah Supreme Court interpreted the phrase accidental means in a disability policy to include disability that was unexpected even though the activity leading to the disability was intentional. In contrast, in Elton, the same court appears more concerned with whether the event that caused the loss was sudden and unexpected than with whether the loss itself was unexpected. Thus, the court suggested that a heart attack due to stress does not come within the ordinary meaning of the word accident, notwithstanding the fact that a heart attack victim generally does not expect its occurrence. See 516 P.2d at 174-76. The court in Hoffman v. Life Ins. Co. of North America, 669 P.2d 410 (Utah 1983), provides language that at first glance seems to indicate an adoption of the accidental means approach: a person is a victim of an accident when, from the victim's point of view, the occurrence causing the injury or death is not a natural and probable result of the victim's own acts. Id. at 416 (emphasis omitted). The court's subsequent discussion, however, makes clear that the court in fact embraces the other, less strict, standard: the common meaning of the term [accident] is defined in terms of whether the event was naturally and probably expected or anticipated by the insured. Id. We are convinced that the Utah courts currently use the less strict standard of defining accidental as a result that was not reasonably foreseeable even if the means causing the result was foreseeable or even intentional. See, e.g., Hardy v. Beneficial Life Ins. Co., 787 P.2d 1, 2-3 (Utah App.), cert. denied, 795 P.2d 1138 (Utah 1990). 35 Mr. Winchester presumably did not reasonably foresee suffering heart failure as a result of his participation in the firefighting exercise. Therefore, under the current state of Utah law, his death was accidental, thereby satisfying the second condition of the policy. 36 C. Directly and Independently of All Other Causes 37 We finally consider whether [t]he injury, directly and independently of all other causes, resulted in the loss [emphasis added]. The policy thus makes clear that this provision excludes losses resulting even in part from preexisting conditions. This theme is echoed in the exclusions, which state that [a]ny loss which results ... directly or indirectly from bodily or mental infirmity or disease is not covered. Thus, if Mr. Winchester did have a preexisting infirmity, such as a heart condition, then his death did not result directly and independently of all other causes. 38 One issue in dispute in this case was whether long-term smoking had led to a heart condition that made Mr. Winchester more prone to heart failure. The appellant argues that because this fact was in dispute, we must assume for purposes of summary judgment that no preexisting infirmity contributed to the loss. Given the state of the record before the district court, we disagree. 39 In order to prevail on the merits, the appellant had to prove that the death occurred independently of any other cause, including a preexisting bodily infirmity. [T]he inquiry involved in a ruling on a motion for summary judgment ... necessarily implicates the substantive evidentiary standard of proof that would apply at the trial on the merits. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252, 106 S.Ct. 2505, 2512, 91 L.Ed.2d 202 (1986). The judge's inquiry ... unavoidably asks whether reasonable jurors could find by a preponderance of the evidence that the plaintiff is entitled to a verdict--'whether there is [evidence] upon which a jury can properly proceed to find a verdict for the party producing it, upon whom the onus of proof is imposed.'  Id. (citation omitted; alteration in original). 40 In this case, the appellant needed to prove by a preponderance of the evidence that her husband's death fell within the terms of the insurance policy. However, her own expert conceded that people that have heart attacks generally have heart disease. Aplee Supp.App. at 54. 6 Thus, the appellant's own evidence indicated that it was more likely than not that Mr. Winchester had preexisting heart disease. Given that no autopsy was performed nor was any other evidence available as to the precise cause of death, the appellant could not have refuted this likelihood set forth by her own witness of a preexisting infirmity. Therefore, the appellant could not have met her burden of proof of showing that her husband's death met the insurance policy's third condition. This represents a third basis for upholding the district court's granting summary judgment in favor of Prudential.