Ganapolsky v. Boston Mut. Life Ins. Co.

• Decision Date: 05 November 1997
• Docket Number: No. 96-2255,96-2255
• Citation: 138 F.3d 446
• Parties: Dr. Israel GANAPOLSKY, Plaintiff, Appellant, v. BOSTON MUTUAL LIFE INSURANCE COMPANY, et al., Defendants, Appellees. . Heard
• Court: U.S. Court of Appeals — First Circuit

Page 446

138 F.3d 446

Dr. Israel GANAPOLSKY, Plaintiff, Appellant, v. BOSTON MUTUAL LIFE INSURANCE COMPANY, et al., Defendants, Appellees.

No. 96-2255.

United States Court of Appeals First Circuit.

Heard Nov. 5, 1997.

Decided March 17, 1998.

Rehearing Denied April 14, 1998.

Kevin G. Little, with whom David Efrn, San Juan, PR, and Law Offices David Efrn, were on brief for appellant.

Guillermo de Guzman-Vendrell, Hato Rey, PR, with whom Victoria D. Pierce and Cancio, Nadal, Rivera & Daz, San Juan, PR, were on brief, for appellees.

Before TORRUELLA, Chief Judge, CYR, Senior Circuit Judge, LYNCH, Circuit Judge.

TORRUELLA, Chief Judge.

Israel Ganapolsky ("Ganapolsky"), a medical doctor from Puerto Rico, filed this action against his insurer, Boston Mutual Life Insurance Company ("Boston Mutual"), to recover under an accidental death and dismemberment policy for the partial amputation of his left foot. Boston Mutual had denied Ganapolsky's claim for the loss. On a stipulated record, the district court entered judgment in favor of Boston Mutual, and Ganapolsky appeals. We affirm.

The following facts are essentially undisputed. On June 5, 1992, while in New York City, Ganapolsky accidentally injured his left foot when he tripped on a two-inch step at the entrance to the men's room of a theater. The next day, Ganapolsky continued with his planned trips to Turkey and Israel, but was forced to cut his travel short and return to Puerto Rico after approximately two weeks due to increasing problems with his foot. At the hospital in Puerto Rico where he was admitted, Ganapolsky was diagnosed with gangrene in his left foot and a below-the-knee amputation was recommended. In addition, for the first time, it was discovered that Ganapolsky had diabetes. Ganapolsky travelled to Union Memorial Hospital in Baltimore, Maryland to seek treatment for his foot. There, his doctor performed a "Chopart" amputation, which, as the district court aptly observed, "can best be visualized as a cut going from the point on top of the foot approximately where a man's shoelace is knotted down to the bottom of the foot, leaving the heel." Ganapolsky v. Boston Mut. Life Ins. Co., Civ. No. 94-2229, slip op. at 2 (D.P.R. July 3, 1996).

Thereafter, Ganapolsky filed a claim with Boston Mutual for benefits under a group accidental death and dismemberment policy (the "policy") for the Chopart amputation of his left foot. Boston Mutual denied the claim for the following reasons: first, the policy required that the loss of a foot be a complete severance through or above the ankle joint, and Ganapolsky's amputation was not one through or above the ankle joint; and second, the policy excludes loss resulting from sickness, disease or bodily infirmity, and in the instant case, diabetes and diabetic neuropathy were instrumental causes of the eventual amputation.

We review a district court's factual determinations for clear error, see Sullivan v. Young Bros. & Co., Inc., 91 F.3d 242, 246-47 (1st Cir.1996), and its legal determinations de novo, see Bercovitch v. Baldwin Sch., Inc., 133 F.3d 141, 147 (1st Cir.1998). The insurance policy at issue provides in relevant part:

We agree to pay benefits for loss from bodily injuries:

a)caused by an accident which happens while an insured is covered by this policy; and

b)which, directly and from no other causes, result in a covered loss.

(Emphasis added.) The policy also excludes coverage for "loss resulting from ... [s]ickness, disease or bodily infirmity." Boston Mutual argues that this policy exclusion applies to the instant case, and thus, that it properly denied coverage. We agree. The trial judge concluded that the amputation did not come from the foot injury within the meaning of the policy language of 'directly and from no other causes.' "

In this action based on diversity jurisdiction, the substantive law of Puerto Rico governs. See Erie R.R. Co. v. Tompkins, 304 U.S. 64, 58 S.Ct. 817, 82 L.Ed. 1188 (1938). Under Puerto Rico law, an exclusion clause in an insurance contract is strictly construed and any ambiguity is resolved in favor of the insured. See Pagan Caraballo v. Silva Delgado, 122 P.R. Dec. 105, 110-11 (1988). However, where the language of the exclusion unambiguously supports the insurer, the court need not strain to find a construction favoring the insured. See Marn v. American Int'l Ins. Co. of P.R., 137 P.R. Dec. ----, 94 J.T.S. 132 (Oct. 28, 1994).

Under the policy, as we previously noted, covered losses are only those resulting directly from accidents and "from no other causes." The exclusion clause specifically bars coverage for losses resulting from sickness, disease or bodily infirmity. According to Couch on Insurance 2d § 41:74, at 112 (Rev. ed.1982),

If a disease or bodily condition exists and an accident occurs, ... it is sufficient if the accidental means would have solely caused some considerable injury had the disease or bodily condition not existed. But if no considerable injury at all would have...