Court Opinion

ID: 9727675
Source: CourtListenerOpinion
Date Created: 2023-08-26 13:47:12.092781+00
Date Added: 2024-06-11T18:25:41.297309
License: Public Domain

SAUFLEY, C.J.,
with whom CLIFFORD and RUDMAN, JJ., join, dissenting.
[¶ 21] The Court in this case concludes that, absent a disease exclusion like the one found in Bouchard v. Prudential Insurance Co. of America, 135 Me. 238, 239, 194 A. 405, 406 (1937), the language of the policy requiring that the accident “creates a loss due, directly and independently of all other causes, to such accidental injury” entitles an insured to losses actually caused by pre-existing medical conditions rather than the accident. In my view, this proposition is supported by neither the plain language of the policy nor by our prior decisions. Thus, I respectfully dissent.
[¶ 22] The Court has engaged in a definitional tautology — a medical condition that causes the loss of a limb is not a cause because it is a medical condition. The requirement that the accident cause the injury “directly and independently of all other causes,” by its plain language prohibits the contribution of any kind of cause, including that of a pre-existing medical condition. Although a person need not be in perfect health at the time of the accident to recover,3 when a pre-existing medical condition contributes to the ultimate loss in some meaningful way, the accident cannot be found to have been the sole cause of the loss, “directly and independently of all other causes.” Thus, recovery would be barred by the exclusive cause condition when a pre-existing medical condition meaningfully contributes to the loss. Holding otherwise converts this very inexpensive, highly focused insurance policy into one encompassing coverage for a multitude of losses caused by a combination of the impaired health of the insured and an accident. Inexpensive, readily available, and limited, accident insurance has now become a form of health insurance. The contract unambiguously excludes such a result.
[¶ 23] Furthermore, Bouchard is, in fact, instructive. Although in Bouchard, unlike the present case, the insurance policy also contained a disease exclusion that denied payment if death resulted “directly or indirectly from bodily or mental infirmity or disease in any form,” our analysis and holding relied not on this disease exclusion, but rather on the language of the exclusive cause condition virtually identical to the one in Pelkey’s policy with General Electric. Bouchard, 135 Me. at 239, 194 A. at 406. Our conclusion in Bouchard was based on the rule that “[w]hen at the time of the accident there was an existing disease, which, co-operating with the accident, resulted in the injury or death, the accident cannot be considered as the sole cause or as the cause independent of all other causes.” Id. at 243, 194 A. at 408. As such, the insured’s loss was not covered by his policy pursuant to the exclusive cause condition. Id.
[¶ 24] This is exactly the case here. The parties stipulated that Pelkey’s pre-exist-ing medical conditions were “substantial contributing factors” to the eventual amputation of his leg, and that the accidental fall alone would not have resulted in the loss of his leg. These stipulations place *391Pelkey’s circumstances squarely outside the language of the contract that permits recovery only when the loss is due, “directly and independently of all other causes” to the accidental injury. I would therefore affirm the judgment of the Superior Court in favor of General Electric.

. Even a person in less than perfect health will recover for an injury caused by an accident unless that person’s health problems are medically related to the loss.