In Estate of Maurice v. Life Ins. Co. of N. Am., 792 Fed. Appx. 499 (9th Cir. Cal. Feb. 5, 2020), the Ninth Circuit held that coverage was excluded under an ERISA-governed disability plan ("Plan"), because the evidence in the record demonstrated that the covered participant's underlying diabetes substantially contributed to an infection that led to the amputation of his foot—and ultimately his death—after he stepped on a piece of glass.
The Plan at issue provided accidental death benefits if "[a] sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss" and is "not contributed to by disease, Sickness, mental or bodily infirmity," and " not otherwise excluded under the terms of this Policy." The Plan excluded "any Covered Injury or Covered Loss, which, directly or indirectly, in whole or in part, is caused by or results from … illness or disease." Estate of Maurice v. Life Ins. Co. of N. Am., 2018 U.S. Dist. LEXIS 93807, at *2-3 (C.D. Cal. June 4, 2018).
The evidence in the record before the district court showed that the deceased had cut his foot on glass in May of 2008. The deceased, who had diabetes, developed a serious infection and complications as a result of his injury. Despite several surgeries and a partial amputation of his foot, the deceased ultimately had his left leg amputated in 2015, and died several months later. The death certificate listed the immediate cause of death as ventricular fibrillation, with congestive heart failure and aortic stenosis, and listed diabetes mellitus as a significant condition contributing to death.
The claim administrator and insurer for the Plan, LINA, determined that no AD&D benefits were payable, in part, because decedent's pre-existing diabetes significantly contributed to his death and was thus excluded by the terms of the Plan. The district court, under a de novo standard of review, ruled that the exclusion did not apply, because the evidence in the record failed to demonstrate that the decedent's amputation was "significantly contributed to" by an underlying sickness or disease; LINA appealed.
On appeal, the Ninth Circuit reserved. The court reasoned that the Plan did not provide coverage "if a preexisting condition substantially contributed to the disability." Citing its recent decision in Dowdy v. Metro. Life Ins. Co., 890 F.3d 802, 809 (9th Cir. 2018), the Ninth Circuit explained:
"The word 'substantial' is used to denote the fact that [the condition] has such an effect in producing the harm as to lead reasonable men to regard it as a cause, using that word in the popular sense, in which there always lurks the idea of responsibility, rather than in the so-called [**3] 'philosophic sense,' which includes every one of the great number of events without which any happening would not have occurred. [internal citations omitted]. … For a court to distinguish between a responsible cause and a 'philosophic,' insignificant cause, there must be some evidence of a significant magnitude of causation. Such evidence need not be presented with mathematical precision, but must nonetheless demonstrate that a causal or contributing factor was more than merely related to the injury, and was instead a substantial catalyst."
Reviewing the evidence presented in the underlying record, the Ninth Circuit noted that the decedent's own medical expert opined that his diabetes prevented the cuts on his foot from healing properly, increased the risk of infection, and made it more difficult to fight the "bacterial onslaught" that allowed the infection to reach the bone. The evidence showed that the only way to stop the infection from spreading further was to amputate the decedent's leg. The court found that the effects of decedent's pre-existing diabetes were extensive and well-documented.
In sum, the Ninth Circuit found the conclusion "inescapable" that decedent's diabetes "substantially contributed" to the amputation of his leg and ultimate death, and was therefore a loss excluded from coverage.
