Sekel v. Aetna Life Ins. Co., 81-1484

Decision Date19 May 1983
Docket NumberNo. 81-1484,81-1484
Citation704 F.2d 1335
PartiesJudith SEKEL, Plaintiff-Appellee, v. AETNA LIFE INSURANCE COMPANY, Defendant-Appellant.
CourtU.S. Court of Appeals — Fifth Circuit

Locke, Purnell, Boren, Laney & Neely, Larry M. Lesh, Robert T. Mowrey, Dallas, Tex., for defendant-appellant.

Martin Barenblat, Dallas, Tex., for plaintiff-appellee.

Appeal from the United States District Court for the Northern District of Texas.

Before THORNBERRY, REAVLEY and GARWOOD, Circuit Judges.

GARWOOD, Circuit Judge:

This is a Texas diversity case between Aetna Life Insurance Company and Mrs. Judith Sekel, involving the construction of an exclusion clause as applied to accidental death benefits under Aetna combined group life and accidental death policies in which Mrs. Sekel is the named beneficiary. The issue presented for our consideration is whether the language of the exclusion clause bars recovery of accidental death benefits respecting a death, a functionally closely related significant contributing factor or cause of which is a "bodily infirmity" or "disease," but whose more immediately precipitating and proximate cause is accidental bodily injury. The district court, ruling on cross-motions for summary judgment, held for the beneficiary that it did not. Concluding that the exclusion clause in the policy does bar recovery, we reverse.

THE FACTS

On August 12, 1978, Mrs. Sekel's late husband, Richard Sekel, insured under Aetna's combined group life and accident policies issued in 1973 to his employer under a single certificate, fell to the floor at his home and sustained a "severe" blow to his head, which resulted in his death within approximately one hour following the fall. Mr. Sekel had a "severe atherosclerotic and hypertensive cardiovascular disease" which the autopsy report, completed by three physicians, concluded had probably caused his fall. The parties stipulated that this report and the death certificate "accurately and correctly set forth" "the facts regarding the cause of death." The report states:

"In our opinion Richard Sekel, a 62 year old white male, died from severe head trauma, which included fracturing of the base of the skull and bruises of the brain surfaces. The initiating event was probably an arrhythemia (failure of the heart to beat properly) secondary to the victim's very severe hypertensive and atherosclerotic cardiovascular disease (high blood pressure and hardening of the arteries). Therefore, the victim probably 'passed out' because of his natural disease processes and subsequently struck his head when he fell."

The foregoing is the only relevant evidence as to the cause of death. Mrs. Sekel, as beneficiary, received benefits from Aetna for the life insurance coverage, but was denied them under the accident coverage. The accident benefits coverage clause states that Aetna will pay the stipulated benefits, if Mr. Sekel suffers a "bodily injury caused by an accident and as a direct result of such injury and, to the exclusion of all other causes, sustains within not more than ninety days ... any of the losses [covered]." Aetna does not expressly contest that Mr. Sekel's accidental death falls within these terms. It maintains, however, that the exclusion clause in the policy precludes Mrs. Sekel's recovery of accidental death benefits. This clause states:

"The insurance provided under this Title does not include, and no payment shall be made for, any loss resulting from any injury caused or contributed to by, or as a consequence of, any of the following excluded risks, even though the proximate or precipitating cause of loss is accidental bodily injury:

"(a) bodily or mental infirmity; or

"(b) disease...."

The sole issue for our consideration is whether this exclusion clause bars Judith Sekel's accidental death benefit recovery.

THE LAW

The coverage clause in the Aetna policy is similar to those in many other accidental death or disability policies, which typically provide that an insured can only recover if the loss is "directly and independently" or "independently and exclusively" caused by an accident. In Texas and most other jurisdictions these clauses have been construed to preclude recovery where disease or bodily infirmity is a concurrent proximate cause of death. Mutual Benefit Health & Accident Association v. Hudman, 398 S.W.2d 110, 115 (Tex.1965); 10 G. Couch, R. Anderson, & M. Rhodes, Couch on Insurance 2d, Sec. 41:75 at 113-14 (rev. vol. 10, 1982); and see 1B Appleman, Insurance Law & Practice Sec. 393 at 64-73 (rev. vol. 1B 1981). Where such disease is found to be a "remote" cause, however, courts have not barred recovery. Stroburg v. Insurance Company of North America, 464 S.W.2d 827, 829-31 (Tex.1971); Appleman, Sec. 393 at 81; Couch, Sec. 41:79-80 at 128-33.

Many policies also contain an exclusion clause which specifically disallows recovery where disease caused or contributed to the loss. In Stroburg v. Insurance Company of North America, the Texas Supreme Court recognized two types of exclusion clauses, those which excluded coverage only when disease was a proximate cause, and those which also excluded it when disease was a more remote cause, of the loss. In the first category was the clause presented in that case which provided that "[t]his policy does not cover loss caused by or resulting from any one or more of the following: ... [i]llness, disease ... bodily infirmity...." The court cited as an example of the second type those clauses which included language excluding liability if disease or bodily infirmity contributed "directly or indirectly" to the loss. 464 S.W.2d at 831-32. We must decide whether the Aetna exclusion clause falls into this second category, effectively excluding coverage where disease, though a functionally closely related significant contributing factor or cause is nevertheless neither a concurrent proximate nor the most immediately precipitating cause of loss, or into the first category, excluding coverage only where disease is at least a concurrent proximate cause.

In doing so we are guided by the principles which govern the construction of insurance contracts under Texas law. These principles were well summarized in Glover v. National Insurance Underwriters, 545 S.W.2d 755, 761 (Tex.1977):

"[E]xceptions and rules of limitation will be strictly construed against the insurer. Further, we must adopt the construction of an exclusionary clause urged by the insured as long as that construction is not itself unreasonable, even if the construction urged by the insurer appears to be more reasonable or a more accurate reflection of the parties' intent. [Citations omitted.] On the other hand, we recognize that these rules of construction will be applied only when the language of the policy is such that it may reasonably be given one of several constructions. [Citation omitted.] In other words, the plain language of an insurance policy, like that of any other contract, will be given effect when the parties' intent may be discerned from that language. But when the language of an insurance contract is ambiguous, that is, is subject to two or more reasonable interpretations, then that construction which affords coverage will be the one adopted."

We now examine the words of the Aetna policy to determine how these principles apply. The exclusion clause in this policy denies coverage for accidental death benefits respecting "any loss resulting from any injury caused or contributed to by, or as a consequence of, any of the ... excluded risks, even though the proximate or precipitating cause of loss is accidental bodily injury." 1 This language contemplates a situation where "the proximate or precipitating cause of loss" is accidental bodily injury, and makes clear that, "even though" the accidental injury is the proximate or precipitating cause, if disease or bodily infirmity is also a contributing factor or cause, there is no coverage. Since the exclusion clause by its terms is applicable when the proximate or precipitating cause of loss is an accidental injury, necessarily implicit in its meaning is that other contributing factors or causes which the policy excludes (e.g., "bodily or mental infirmity" or "disease") need not be concurrent proximate or as immediately precipitating causes for the exclusion to have effect. Thus, a loss, a functionally closely related significant cause or contributing factor of which is a noncovered risk, is excluded from the policy's accidental death benefits even though a covered risk is the proximate and more immediately precipitating cause of the loss.

The exclusion clause is clear and unambiguous in conveying this meaning. As such, the principle of construing insurance contracts strictly against the insurer does not apply, Southern Life and Health Insurance Co. v. Simon, 416 S.W.2d 793, 795 (Tex.1967); Gulf Atlantic Life Insurance Co. v. Disbro, 613 S.W.2d 511, 512 (Tex.Civ.App.--Beaumont 1981, no writ), and we must give the language of the policy its plain meaning. Argonaut Southwest Insurance Co. v. American Home Assurance Co., 483 F.Supp. 724, 727 (N.D.Tex.1980); Vanguard Insurance Co. v. Stewart, 593 S.W.2d 736, 739 (Tex.Civ.App.--Houston [1st Dist.] 1979), aff'd, 603 S.W.2d 761 (Tex.1980); American-Amicable Life Insurance Co. v. Lawson, 419 S.W.2d 823, 826 (Tex.1967); Republic National Life Insurance Co. v. Spillars, 368 S.W.2d 92, 94 (Tex.1963).

We conclude that the Aetna exclusion clause is of the second type described in the Stroburg decision, and coverage is barred when a risk excluded by the policy is a functionally closely related significant cause or contributing factor of the loss even though a covered risk is the proximate and more immediate precipitating cause. A contrary interpretation disregards the clear and unambiguous meaning of the exclusion clause, especially its "even though" phrase. Mr. Sekel's heart condition, the "natural disease processes" of which caused him to pass out and...

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