Eleanor Crose v. Humana Insurance Company
823 F.3d 344
5th Cir.2016Background
- On June 23–24, 2013, Ronald Crose ingested ecstasy; the next morning he was found non‑responsive and transported to the hospital with a large intracerebral hemorrhage and subarachnoid component.
- Emergency records and physicians’ notes recorded positive drug screens for amphetamines (ecstasy), benzodiazepines, and cannabinoids, and physicians linked the stroke to hypertension likely triggered by ecstasy.
- Mr. Crose had an individual Humana health policy containing a causation exclusion: “Loss due to being intoxicated or under the influence of any narcotic unless administered on the advice of a health care practitioner.”
- Humana denied coverage relying on that exclusion; Eleanor Crose sued for breach of contract, unfair insurance practices, and prompt payment violations under Texas law.
- The district court granted Humana summary judgment; Mrs. Crose appealed. The Fifth Circuit reviewed de novo and affirmed summary judgment for Humana.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether “narcotic” is ambiguous and excludes ecstasy | Crose: “narcotic” is a technical term limited to plant‑derived opioids; ecstasy is a hallucinogen, not a narcotic | Humana: ordinary meaning of “narcotic” covers illicit mood‑altering drugs including ecstasy; technical definitions are unreasonable absent policy language | The term is given its ordinary meaning; “narcotic” includes ecstasy (no ambiguity) |
| Proper causation standard for exclusion phrasing “due to” | Crose: Humana must show ecstasy was the sole cause or at least more than a minimal cause | Humana: exclusion requires a direct causal link between intoxication and loss | Court: “due to” requires proximate causation; insurer must show intoxication was a significant/substantial (proximate) cause, not the sole cause |
| Whether Humana met its burden to prove causation | Crose: Humana failed to prove ecstasy was a substantial proximate cause; contested medical causation and lack of exclusive proof | Humana: medical records, treating physicians’ opinions, expert reports, literature, and temporal proximity show ecstasy induced hypertension which substantially caused the stroke | Held: Humana met its burden—evidence shows ecstasy use substantially contributed to hypertension and the stroke; exclusion applies |
| Appealability of unfair insurance practice claims | Crose: claims are intertwined with breach of contract, so preserved on appeal | Humana: Crose failed to brief those claims on appeal | Held: Crose waived appellate challenge to unfair practice claims by not addressing them in opening brief |
Key Cases Cited
- Utica Nat’l Ins. Co. v. Am. Indem. Co., 141 S.W.3d 198 (Tex. 2004) (interpreting “due to” in an exclusion to require a more direct causal nexus than mere but‑for causation)
- Likens v. Hartford Life & Accident Ins. Co., 688 F.3d 197 (5th Cir. 2012) (intoxication exclusion requires intoxication be a proximate, substantial cause of loss)
- Gilbert Tex. Const., L.P. v. Underwriters at Lloyd’s London, 327 S.W.3d 118 (Tex. 2010) (undefined policy terms receive ordinary meaning unless a technical sense is shown)
- Kelly Assocs., Ltd. v. Aetna Cas. & Sur. Co., 681 S.W.2d 593 (Tex. 1984) (ambiguous policy terms construed in favor of the insured)
- Health Care Serv. Corp. v. Methodist Hosps. of Dallas, 814 F.3d 242 (5th Cir. 2016) (standards for de novo review of summary judgment)
- Data Specialties, Inc. v. Transcont’l Ins. Co., 125 F.3d 909 (5th Cir. 1997) (insured must first show claim falls within the insuring agreement; burden shifts to insurer to prove exclusion applies)