Gloria Wells v. Minnesota Life Insurance Co.
885 F.3d 885
5th Cir.2018Background
- Insured Melton Wells (68) contracted West Nile Encephalitis (WNE) and died ~4 weeks after hospital admission; death certificate lists WNE and related complications and marks death as "natural."
- Gloria Wells (wife) claimed accidental-death benefits under a Minnesota Life Decreasing Term Accidental Death Policy; insurer denied benefits citing lack of an accidental bodily injury as sole cause and an illness/infirmity exclusion.
- Policy insuring clause covers death "directly and independently from all other causes" from an "accidental bodily injury" that is "unintended, unexpected and unforeseen," evidenced by a visible contusion or wound, and the injury must be the "sole cause" of death within 90 days.
- Exclusion Four bars coverage where death "is caused directly or indirectly by, results from, or there is contribution from ... bodily or mental infirmity, illness or disease." Terms like "accidental bodily injury," "wound," "disease," and "sole cause" are undefined.
- District court granted summary judgment for Minnesota Life on breach-of-contract and bad-faith claims; Fifth Circuit reverses summary judgment on breach-of-contract (genuine fact disputes) and affirms dismissal of bad-faith claim (insurer had reasonable basis to deny).
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether mosquito bite was an "accidental bodily injury" (unintended, unexpected, unforeseen) | The WNV-infected Culex mosquito bite was an unforeseen, determinate external act and thus an accidental bodily injury | Mosquito bites are common/environmental and infection from everyday exposure is not an "accident"; CDC death certificate shows natural cause | Genuine dispute of material fact exists; question for factfinder (reverses summary judgment) |
| Whether the accidental injury was the "sole cause" of death | Complications (respiratory failure, septic shock, multisystem failure) resulted from WNE and thus are secondary to the accident, not independent concurrent proximate causes | Death certificate lists multiple direct causes; those complications (and preexisting conditions) are concurrent proximate causes that defeat "sole cause" requirement | "Sole cause" ambiguous; under a reasonable construction, complications arising solely from the accident are not concurrent proximate causes; genuine factual dispute exists |
| Whether the bite was "evidenced by a visible contusion or wound" | Circumstantial evidence (WNE diagnosis, experts noting mosquito transmission, spouse's statement) permits a reasonable inference that a mosquito bite/wound occurred | No direct record evidence of a visible wound or contusion | Circumstantial evidence suffices at summary-judgment stage to create a fact issue; remand for factfinder |
| Whether Exclusion Four (illness/infirmity/disease) bars coverage | Exclusion should not apply to illnesses that are caused by the accidental injury itself; exclusion reasonably read to cover preexisting or independent diseases only | WNE is plainly an "illness" or "disease" contributing to death, so exclusion applies | Exclusion ambiguous as to whether it covers conditions that result from the accident; genuine factual dispute over contribution of preexisting conditions and whether post-accident complications fall within exclusion; summary judgment improper on breach claim |
Key Cases Cited
- Mutual Benefit Health & Accident Ass'n v. Hudman, 398 S.W.2d 110 (Tex. 1965) (articulates "sole proximate cause" rule for accidental-death policies)
- Sekel v. Aetna Life Ins. Co., 704 F.2d 1335 (5th Cir. 1983) (concurrent proximate cause and exclusion interpretation)
- Stroburg v. Ins. Co. of N. Am., 464 S.W.2d 827 (Tex. 1971) (death certificate is prima facie, not conclusive, evidence for insurance coverage)
- Crose v. Humana Ins. Co., 823 F.3d 344 (5th Cir. 2016) (standard of review for summary judgment)
- Anderson v. Liberty Lobby, Inc., 477 U.S. 242 (Sup. Ct. 1986) (summary-judgment standard: reasonable jury reference)
- Thompson v. Zurich Am. Ins. Co., 664 F.3d 62 (5th Cir. 2011) (insurer may breach duty of good faith by failing to reasonably investigate)