Mortgage holders in Grand Prairie, Weatherford, Arlington, Aledo, Azle, Fort Worth, Dallas, Irving, Hurst, Euless, Bedford, Pantego, and other places in Texas would find an interest in the case discussed below.
The United States Court of Appeals for the Fifth Circuit, issued an opinion on March 18, 2011, styled, Brenda LeMeilleur v. Monumental Life Insurance Company: Trustees of the National Homeowners Group Insurance Trust, c/o Countrywide Insurance Services, Incorporated. This case is an appeal from the district court where a ruling was handed down in favor of the insurance company. That ruling was affirmed by this appeals court.
Here are some facts:
Mrs. LeMeilleur sued the insurance company to recover an accidental death benefit from a Group Mortgage Accidental Death Policy (“Policy”) which her deceased husband held.
Mrs. LeMeilleur and her husband purchased the Policy from Monumental. If Mr. or Mrs. LeMeilleur suffered an accidental death, the Policy states it would pay off the balance of the couple’s home mortgage. The Policy also states that Monumental will pay the accidental death benefit when they “receive proof that the Insured died as a result of an Injury. The Policy defines an “Injury” as a “bodily Injury caused by an accident, independently of all other causes” and further stipulates that the “Injury must be the sole and direct cause of death.” In September 2005, Mr. LeMeilleur fell and broke his hip, which required surgery. In July 2006, he died. According to Mr. LeMeilleur’s death certificate, his death was due to a heart attack with hypertension as an underlying cause. Mrs. LeMeilleur submitted a claim for a death benefit for Mr. LeMeilleur’s death, which Monumental denied. In court, Mrs. LeMeilleur argued that she was entitled to the death benefit because her husband’s death was due to an insured accident – the fall. Mrs. LeMeilleur supported her contention with testimony from Dr. Milton Shaw, Mr. LeMeilleur’s attending physician.
In its discussion of the case the court said, “all parts of the contract are to be taken together, and such meaning shall be given to them as will carry out and effectuate to the fullest extent the intention of the parties.” “It is well established that a contract is to be construed in accordance with its plain language.” They also said that policy language that is susceptible to more than one construction should be interpreted strictly against the insurer and liberally in favor of the insured. In an accidental death benefit claim, the combination of an accident and pre-existing conditions are insufficient for recovery. An accident must be more than a “proximate cause” of death, it must be the “sole proximate cause.”
In this case, Mr. LeMeilleur had pre-exisiting conditions and the policy had language accepting these pre-existing conditions. Mrs. LeMeilleur claimed this kept Monumental from denying the claim. But as the court pointed out in its discussion of the case, Monumental did not deny the claim because of pre-existing illnesses or conditions. Monumental denied the claim because the accident in question, Mr. LeMeilleur’s fall, was not the sole cause of death. Rather, he died due to heart failure and hypertension.
Mr. LeMeilleur’s death certificate did not reference the fall and lists a heart attack as the immediate cause of death. And, Mrs. LeMeilleur’s own expert, Dr. Shaw, testified that the fall was merely a contributing factor to Mr. LeMeilleur’s death, not the sole cause of death. The connection between the fall and the death claim failed because there was no evidence to support her contention that the fall was the sole cause of death.
This case, or at least what appears in the written decision, does not appear to have been a hard call for the appeals court.
One thing an experienced Insurance Law Attorney would want to know more about is the language in the policy that talked about pre-existing conditions. This is brought up in the discussion of the case but is not discussed in much detail. A footnote in the case alludes to this not being adequately discussed at the trial level and thus was not subject to review by the appeals court.
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