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Fifth Circuit Court Reverses the Denial of Accidental Death Insurance Benefits in a West Nile Virus Case

April 30, 2018 Posted in Blog

On March 22, 2018, the Fifth Circuit Court of Appeals — in Wells v. Minnesota Life Insurance Co., where the defendant-insurer denied accidental death coverage to the plaintiff under her husband’s accidental death mortgage  insurance policy — reversed the ruling of the lower district court on  our client’s (the plaintiff Gloria Wells)  breach of contract claim against the insurer for their denial of accidental death benefits.  The district court had earlier dismissed our plaintiff’s claims on summary judgment, but the Fifth Circuit Court determined that there were genuine disputes of material facts as to whether the death of the husband qualified for accidental death coverage under the accidental death insurance policy.

Worth noting: The Fifth Circuit Court affirmed (e.g. confirmed) the district court ‘s ruling in dismissing the bad faith claims since the insurance company had at least a reasonable basis to deny benefits according to the Fifth Circuit. A petition for rehearing on this issue is pending.

As such, the Court remanded the case back to the lower court so that a jury could decide the disputed facts.  The decision of the Fifth Circuit Court of Appeals to reverse and remand has given our client a fresh opportunity to have her breach of contract claim evaluated with full consideration of the facts. For additional information and comments from our Houston attorney, Jim Plummer, see the article published by the Texas Lawyer.

The Case at a Glance

The Minnesota Life Insurance Co. policy was a declining balance mortgage insurance policy intended to pay off the balance of the insured’s mortgage in the event of the accidental death of its insured.  Here, the plaintiff’s husband — Melton Dean Wells — was bitten by a mosquito carrying West Nile Virus, unbeknownst to him.  Melton went to the hospital for diagnosis and treatment, as he was suffering from a broad range of symptoms that included fever, headache, and altered mental status.  The doctors soon diagnosed Melton with West Nile encephalitis, which is caused by the West Nile Virus (transmitted to humans by infected mosquitos).  Within just three weeks, Melton’s body significantly deteriorated, and he died of respiratory failure, multi-system organ failure, and septic shock resulting from West Nile encephalitis.

Melton’s death certificate classified that his death from West Nile encephalitis as “natural, as opposed to accidental.

When Melton’s wife —  Gloria Wells — submitted a claim for accidental death benefits under their accidental death mortgage insurance policy with Minnesota Life Insurance Company, the insurer denied her claim for benefits, asserting that her husband’s death was not due to “accidental bodily injury” and therefore not covered by the policy.  They further asserted that her husband’s West Nile encephalitis had been exacerbated by his pre-existing conditions of obesity, diabetes, and hypertension, along with his age at the time of death (68 years old).

Gloria then filed suit against the defendant-insurer for breach of the insurance contract and bad faith in federal court.

The federal district court dismissed all of Gloria’s claims holding that: a) her husband’s death was not solely caused by West Nile encephalitis, and was instead caused by septic shock, acute respiratory failure, and multi-system organ failure, as noted on the death certificate; b) there was not enough evidence to show that the mosquito bite constituted an accident under the policy; and c) there was no evidence of a visible mosquito bite.  The court further held that even if those factors had been met, a policy exclusion (“Exclusion Four”) would prevent coverage since the death was caused by an illness or disease.  Minnesota Life variously asserted the illness or disease exclusion was Melton’s obesity, diabetes, high blood pressure and his age or those conditions listed on the death certificate.

The denial of her claim left Gloria Wells to struggle with the responsibility for a mortgage on their recently purchased home. 

Believing the district court’s decision was in error, we appealed the decision of the district court.

Does the Mosquito Bite Constitute an Accident Under the Policy?

Minnesota Life’s accidental death mortgage insurance policy provided accidental death coverage only where the insured’s death results from an unintended, unexpected, and unforeseen accidental bodily injury.

The defendant argued (and the district court agreed) that a mosquito bite — particularly in the state of Texas — is not unexpected or unforeseeable.  Our client, however, argued that while mosquito bites may not necessarily be unexpected or unforeseeable in Texas, it is rare for mosquitoes to carry West Nile virus, and as such, it is certainly an unexpected and unforeseeable event to be bitten by a Culex mosquito, the carrier of the West Nile virus.

Worth noting is that the policy does not outright define accidental bodily injury.  Thus, what is accidental is ambiguous and open to interpretation.  The Fifth Circuit Court determined that the bite itself was an external physical force (not an internal bodily process) that gave rise to an unfortunate and unforeseen result.

The defendant attempted to argue that the mosquito bite could not have been accidental since the death certificate indicated that the death was “natural,” but the Fifth Circuit Court was not convinced noting that though the death certificate evidence was some evidence death was natural, the determination of whether an event is accidental is determined by reference to the policy definition of accidental injury.

Was West Nile Virus the Sole Cause of Death?

The policy only provided accidental death coverage when the accidental bodily injury is the sole cause of death.  That bodily injury must also be independent of all other causes. Thus, even if death resulted from an accidental bodily injury, there was no coverage if one of these exclusions applied.   The policy contained 10 exclusions from coverage one of which excluded from coverage death caused “directly or indirectly” by or results from, or there is a contribution from” a “bodily … infirmity, illness or disease.”  This led to a rather tricky situation where Minnesota Life argued Melton’s death was excluded from coverage because of his various conditions (obesity, diabetes, age, etc.)  along with the other contributing causes of death from the death certificate all in addition to the West Nile encephalitis.

Gloria argued, however, that her husband’s various bodily conditions could not have concurrently caused (in other words, “contributed to”) his death if the complications he suffered directly and exclusively resulted from one specific cause: the accidental bodily injury.  Here, the accidental bodily injury was the infected mosquito bite.  Put in simpler terms, Melton would not have died of his various pre-existing conditions unless he had contracted West Nile encephalitis from the mosquito.  The Fifth Circuit Court agreed, and determined that the septic shock, respiratory failure, and multi-system organ failure that Melton suffered were not separate conditions but actually developed as a result of his West Nile encephalitis.

Essentially, the Court determined that any conditions that develop after an accidental injury cannot serve as concurrent causes that preclude coverage.

The Bite Wound Could Be Reasonably Inferred

Though there was no direct evidence of a wound or contusion indicating the Melton had suffered a mosquito bite, Gloria argued that a jury could reasonably infer that her husband had suffered a mosquito bite (and that this had led to a wound or contusion), given that he had clearly contracted West Nile encephalitis, which is most commonly spread by infected mosquitos.

Though the Fifth Circuit Court agreed that there might have been other ways for Melton to have contracted West Nile encephalitis, they determined that a jury could reasonably find that the evidence supported Gloria’s inference argument.

The Fifth Circuit reversed that portion of the district court’s opinion granting summary judgment against Gloria Wells on her breach of the insurance policy and return this case to the district court for a trial on the merits before a jury.  The Fifth Circuit affirmed the district court’s summary judgment on Wells bad faith claims. 

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