Lead Opinion
[¶ 1] Jack Dean Pelkey appeals from the grant of a summary judgment entered in the Superior Court (Penobscot County, Mead, J.) in favor of General Electric Capital Assurance Company. Pelkey contends that the court erred in construing his insurance contract with General Electric Capital Assurance to exclude coverage for the accidental loss of his leg because his pre-existing condition contributed to the loss. Because the policy is ambiguous on the impact of pre-existing conditions, we vacate the judgment.
I. CASE HISTORY
[¶ 2] The case history is developed from the parties’ jointly stipulated facts and a copy of Pelke/s original insurance contract.
[¶ 3] In 1986, Jack Pelkey obtained an accident insurance policy issued by AMEX Life Assurance Company. The policy was procured through Pelke/s credit union, with premiums to be deducted from his account. The coverage clause of the policy provided that:
“Injury” means bodily injury of an Insured Person which: (1) is caused by an accident that occurs while the policy is in force as to the Insured Person; (2) results directly in loss insured by the Policy; (3) creates a loss due, directly and independently of all other causes, to such accidental injury; and (4) occurs in the manner and under the circumstances described in the Descriptions of Hazards which apply.
[¶ 4] The policy also contained an exclusions clause that excluded from coverage losses caused by: (1) being under the influence of alcohol, drugs, or sedatives; (2) committing or attempting to commit illegal acts; or (3) suicide, war, or riding in an aircraft, except as a passenger. The policy contained no exclusions for pre-existing diseases or conditions.
[¶ 5] The policy continued in effect at all times relevant to this case. At some time General Electric Capital Assurance Company became the insurer for the policy.
[¶ 6] In April of 1998, Pelkey suffered an accidental fall resulting in an infection in
[¶ 7] Prior to and during this incident, Pelkey suffered from and received treatment for pre-existing medical conditions, including diabetes and severe peripheral vascular leg disease. Before his accident, Pelkey had undergone a surgical bypass graft in his left leg, which provided the only means of circulation in that leg. The parties stipulated that Pelkey’s pre-exist-ing diabetes, peripheral vascular disease, and impaired circulation in his left leg, together with his fall on April 18, 1998, were substantial contributing factors to his development of infection, septic arthritis, and osteomyelitis, and the eventual amputation. The parties also stipulated that Pelkey’s fall would not have resulted in the osteomyelitis and the need for amputation but for the contribution of the pre-existing-diabetes and vascular disease, and the already precarious circulation in his left leg.
[¶ 8] General Electric determined that the fall was not the sole cause of the amputation and refused to pay pursuant to the policy. Pelkey filed a complaint in the Superior Court alleging breach of contract and unfair claims practices.
II. DISCUSSION
[¶ 9] There appears to be no dispute that the first, second, and fourth elements of the insurance contract’s definition of injury are present in this case. Pelkey contends that coverage of his accidental loss is not excluded by the third element of the injury definition, which requires that the injury “creates a loss due, directly and independently of all other causes, to such accidental injury.” He argues that a preexisting medical condition is not a “cause” within the meaning of the policy and that, because the policy contains no separate “disease exclusion” for pre-existing medical conditions, the loss of his leg is compensable under the contract.
[¶ 10] In reviewing the grant of a summary judgment, we take the evidence in the light most favorable to Pelkey to determine if the court committed any errors of law in the interpretation of his insurance policy. See Acadia Ins. Co. v. Mascis,
[¶ 11] We addressed a similar question in Bouchard v. Prudential Insurance Co. of America. Id. In that case, a restaurant owner died soon after engaging in a physical altercation to remove an unruly patron. Id. at 239,
[¶ 12] In Bouchard, as here, the insured was covered by an accidental loss insurance policy. Id. at 239,
[¶ 13] In justifying its result, the Bou-chard opinion includes, as dictum, some broader language that General Electric argues justifies exclusion of coverage. The dictum in Bouchard indicates that:
(1) When an accident caused a diseased condition, which together with the accident resulted in the injury or death complained of, the accident alone is to be considered the cause of the injury or death.
(2) When at the time of the accident the insured was suffering from some disease, but the disease had no causal connection with the injury or death resulting from the accident, the accident is to be considered as the sole cause.
(3) When at the time of the accident there was an existing disease, which, cooperating with the accident, resulted in the injury or death, the accident can not be considered as the sole cause or as the cause independent of all other causes.
Id. at 243,
[¶ 14] The interpretation urged by General Electric would treat the explicit disease exclusion in Bouchard as surplusage. However, the dictum in Bouchard is appropriately viewed as supporting the lack of coverage based on the disease exclusion, rather than writing the disease exclusion out of the policy.
[¶ 15] The law was the same in 1937 as it is now. Where possible, we construe a contract to give force and effect to all of its provisions, and we avoid an interpretation that renders meaningless any particular provision of the contract. Acadia Ins. Co. v. Buck Constr. Co.,
[¶ 16] With the law in Maine established, since 1937, that an explicit disease exclusion will work to exclude coverage where a disease and an accident combine to produce a loss, a policy that does not include such an exclusion is certainly ambiguous on the issue of whether coverage may be excluded if an accidental event combines with the effects of a disease to produce a loss.
[¶ 17] Today more than ever, we recognize that losses resulting from individual events frequently have several or many causes. See, e.g., Wheeler v. White,
[¶ 18] If General Electric’s interpretation of its policy prevails, there would be no coverage if a loss is affected or aggravated in some small part by: (1) less than perfect speed or skill by emergency personnel responding to a scene; see, e.g., Thompson v. Dep’t of Inland Fisheries & Wildlife,
[¶ 19] Here the ambiguity, if it can be called an ambiguity, is the failure of the General Electric policy to include the so-called “disease exclusion,” which has been recognized as important in Maine law governing such accidental loss policies since 1937. Lacking such a recognized exclusion, the General Electric policy, construed liberally in favor of the insured, must be interpreted to hold that the loss that Mr. Pelkey suffered as a result of his accident is covered under the policy.
[¶ 20] When General Electric accepted Mr. Pelkey’s payments for the policy, it took Mr. Pelkey as it found him — with his pre-existing physical condition. Mr. Pel-key’s loss of his leg would not have occurred but for the accident, which is a covered event. To interpret the policy as General Electric urges would render the
The entry is:
Judgment vacated. Remanded for entry of judgment for the plaintiff, Jack Dean Pelkey.
Notes
. Pelkey later dismissed the count of unfair claims practices.
. Other jurisdictions are split on this point, although the cases rely on differing contract language and legal authority. Compare Kangas v. N.Y. Life Ins. Co.,
Dissenting Opinion
with whom CLIFFORD and RUDMAN, JJ., join, dissenting.
[¶ 21] The Court in this case concludes that, absent a disease exclusion like the one found in Bouchard v. Prudential Insurance Co. of America,
[¶ 22] The Court has engaged in a definitional tautology — a medical condition that causes the loss of a limb is not a cause because it is a medical condition. The requirement that the accident cause the injury “directly and independently of all other causes,” by its plain language prohibits the contribution of any kind of cause, including that of a pre-existing medical condition. Although a person need not be in perfect health at the time of the accident to recover,
[¶ 23] Furthermore, Bouchard is, in fact, instructive. Although in Bouchard, unlike the present case, the insurance policy also contained a disease exclusion that denied payment if death resulted “directly or indirectly from bodily or mental infirmity or disease in any form,” our analysis and holding relied not on this disease exclusion, but rather on the language of the exclusive cause condition virtually identical to the one in Pelkey’s policy with General Electric. Bouchard,
[¶ 24] This is exactly the case here. The parties stipulated that Pelkey’s pre-exist-ing medical conditions were “substantial contributing factors” to the eventual amputation of his leg, and that the accidental fall alone would not have resulted in the loss of his leg. These stipulations place
. Even a person in less than perfect health will recover for an injury caused by an accident unless that person’s health problems are medically related to the loss.