Evans v. Continental Life & Acc. Co.

• Court: Idaho Supreme Court
• Writing for the Court: KNUDSON; McQUADE
• Citation: Evans v. Continental Life & Acc. Co., 398 P.2d 646, 88 Idaho 254 (Idaho 1965)
• Decision Date: 25 January 1965
• Docket Number: No. 9510,9510
• Parties: Mary R. EVANS, Plaintiff-Appellant, v. CONTINENTAL LIFE AND ACCIDENT COMPANY, a corporation, Defendant-Respondent.

Page 646

398 P.2d 646

88 Idaho 254

Mary R. EVANS, Plaintiff-Appellant, v. CONTINENTAL LIFE AND ACCIDENT COMPANY, a corporation, Defendant-Respondent.

No. 9510.

Supreme Court of Idaho.

Jan. 25, 1965.

Thomas A. Mitchell, Coeur d'Alene, for appellant.

Langroise, Clark & Sullivan, Boise, for respondent.

KNUDSON, Justice.

Appellant is the widow of Albert C. Evans, who died of heat stroke on July 16, 1960 while in the employ of the State of Idaho, Department of Highways, at Coeur d'Alene, Idaho. This action was brought to recover $5,604 (being an amount equal to the annual wage of deceased) under the accidental death provisions of a group insurance policy (No. GE 166) issued by respondent under which said deceased was covered as an employee. Appellant is the beneficiary under said policy. The action was tried before the district court sitting without a jury and from a judgment of dismissal this appeal is taken.

Among the facts which are admitted by written stipulation are that the policy here involved provided for payment of an amount equal to one year's salary ($5,604) in the event of the death of the insured, and that said payment on behalf of said Albert C. Evans had been made prior to the filing of this action; that said policy provided for the payment of an additional sum in an amount equal to one year's salary in the case of accidental death of the insured, subject to the terms and conditions set forth in the double indemnity portion of said policy, the salient provisions of which are:

'Upon receipt of notice and due proof, as required herein, that any employee, while insured for Accidental Death, Dismemberment and Loss of Sight Benefits under the policy, shall have sustained any of the losses listed in the following Table of Losses as the direct result of accidental bodily injury

(i) which does not arise out of or in the course of any employment by the Employer, and

(ii) for which he is not entitled to benefits under any Workmen's Compensation law,

and independently of all other causes, as evidenced by a visible contusion or would on the exterior of the body (except in the case of drowning or internal injuries revealed by an autopsy), and the date of occurrence of such injury is not more than ninety days prior to the date such loss was sustained,

the Insurance Company agrees to pay, subject to the terms and conditions hereof, the amount of insurance specified for such loss in the Table of Losses, in accordance with the Full Amount of Insurance applicable to such employee as specified in the Schedule of Benefits.

'TABLE OF LOSSES

In the Event of Loss of:

'The Benefit Will be:

Life -------- The Full Amount of Insurance

* * *

* * *

'No Accidental Death, Dismemberment and Loss of Sight Benefits will be paid for any loss which results directly or indirectly, wholly or partly, from: * * * disease of the body or mental infirmity, or as a result of medical or surgical treatment or diagnosis therefor; * * *'

Appellant assigns as error the following quoted Findings of the trial court, to-wit:

'6. Said death of said Albert C. Evans resulted from a heat stroke which constituted a personal injury received by him caused by an accident arising out of and in the course of his employment by his employer, the State of Idaho.

'7. Prior to the commencement of this action, plaintiff, as claimant, applied for, and subsequently was awarded, and received, Workmen's Compensation benefits pursuant to the Workmen's Compensation law of the State of Idaho, based upon said death of said Albert C. Evans.

'8. Said Albert C. Evans and his beneficiaries were entitled to benefits under the Workmen's Compensation law of the State of Idaho as a result of said accidental personal injury.'

Appellant also assigns as error the court's conclusions of law that Mr. Evans' death was not included within the definition of additional coverage contained in said policy and appellant was not entitled to recover any amount.

An insurance contract is subject to the same rules of legal interpretation as other contracts and the parties thereto, as in other contracts, are bound by the plain terms thereof. In the instant case respondent's obligation to pay must be determined from a consideration of the double indemnity provision hereinbefore set forth. Under this provision respondent's obligation to pay the amount claimed by appellant arises only upon the conditions that if the death occurred:

(1) Independently of all other causes, as the direct result of accidental bodily injury evidenced by a visible contusion or would on the exterior of the body; and

(2) did not arise out of or in the course of any employment by the employer; and

(3) for which appellant as beneficiary is not entitled to benefits under any Workmen's Compensation law.

(4) The policy further provides that notice and due proof of such facts must be submitted to the Insurance Company.

Appellant having commenced this action alleging that she is entitled to benefits in addition to the payments she has admittedly received, the burden of proof rests with her to show that the specific conditions precedent on which the liability is contingent, have taken place. The applicable general rule is stated in Vol. 21 of Appleman--Insurance Law & Practice at page 74 § 12141, as follows:

'In an action on an accident policy, the burden is on the beneficiary to show by evidence that the insurer is liable upon its policy. Likewise, the insured has the burden of showing that his injury was covered by the terms of the policy. * * *'

In New York Life Ins. Co. v. McNeely (1938), 52 Ariz. 181, 79 P.2d 948, the court stated:

'It will be seen by referring to the double indemnity provision above set forth, that it was payable only on proof that the death of the insured resulted directly and independently of all other causes from bodily injury effect solely by external, violent and accidental means. Under a provision of this kind, it is necessary not only that the beneficiary of the policy prove the death of the insured, but also prove affirmatively, by a preponderance of the evidence, that such insured came to his death by reason of the specific causes set forth in the policy, and from those causes only. * * *'

Also in Metropolitan Life Ins. Co. v. Rosier (1941), 189 Okl. 448, 117 P.2d 793, such rule was considered and the court concluded that:

'A fair analysis of the various expressions of this court upon the subject leads to the inevitable conclusion that the rights of the parties to an insurance contract are determinable solely by the provisions of the contract, * * * and that the burden rests upon one who seeks to recover the benefits provided by such contract of indemnity to establish a right of recovery within the legal and proper conditions named in the policy.'

In Washington Nat. Ins. Co. v. Chavez (Tex.Civ.App.1937), 106 S.W.2d 751, the court held that:

'* * * A plaintiff suing on an accident insurance policy has the burden of pleading and proving that insured's death was accidental and not within exceptions. [cases cited]'

See also: Browning v. Equitable Life Assur. Soc. (1938), 94 Utah 570, 80 P.2d 348; Nichols v. New York Life Ins. Co. (1930), 88 Mont. 132, 292 P. 253; Radius v. Travelers Ins. Co. (9 Cir. 1937), 87 F.2d 412.

In Lunt v. Aetna Life Ins. Co. (1928), 261 Mass. 469, 159 N.E. 461, the plaintiff sought to recover on an automobile liability policy. The alleged liability of defendant arose out of an automobile accident in which four persons, the plaintiffs in the original actions against Lunt, were injured. They recovered verdicts. This action was then brought to recover on the policy which provided that the insurer would not be liable for 'accidents to any other employees of the assured, arising out of or in the usual course of the trade, business profession or occupation of the assured.' The court held that the burden was upon the assured to show that the accident was within the terms of the policy; and he could not recover unless there was evidence that the injured parties were not his employees, injured because of the accident involved.

In the case before us appellant introduced evidence to prove that the assured's death resulted from a personal injury received by him which was caused by an accident, and the trial court so found. Appellant complains that the court also found that such accident arose out of and in the course of insured's employment.

The record discloses stipulated admissions on the part of appellant that: (1) at the time of his death Albert C. Evans was employed by the Idaho State Highway Department at an annual wage of $5,604.00; (2) that Albert C. Evans died on property owned by the State of Idaho; (3) that appellant caused to be filed with the State of Idaho as employer of the insured, Mr. Evans, the Idaho State Insurance Fund and the Industrial Accident Board, notices of injury and claims for Workmen's Compensation and death benefits, wherein the accident is described as having happened under the following stated circumstances:

'Mr. Evans had been inspecting samples of concrete,...