Partial Cause v. Sole Cause: Why your insurance company can’t shift the burden to you

Imagine going out to play a game of basketball with your crew. In the heat of the game you tear your Achilles tendon. You’re in pain, but you can rest knowing that your insurance will cover the surgery.

Six days later you have a routine and “uneventful” surgery to repair the tendon and you’re discharged on the same day. However, a couple of weeks later, and after a follow-up with your doctor, you collapse at work, go into cardiopulmonary arrest, and die.

The representative, and beneficiary, of your estate files a claim with your insurance company that purports to provide accidental death and dismemberment coverage for the company’s employees, in the amount of $92,000. However, they deny the claim because your late spouse’s coverage is limited to “bodily injuries. . . that result directly from an accident and independently of all other causes.” The insurance company argues that the basketball player’s death was not the exclusive result of the accident, but additional complications at surgery caused the death. Your representative sues the insurance company on a causation theory—but if not for the Achilles tendon accident, that required surgery, your spouse would not have died.

In a recent case, the 7th U.S. Circuit Court of Appeals was faced with this exact scenario. The lower court ruled in favor of the insurance company, but the 7th Circuit panel was not convinced that that was the right outcome. Judge Posner, writing for the court, explained that the evidence suggesting that the basketball player’s death was caused by a blood clot was inconclusive—it did not show that the blood clot was an independent cause, but merely a partial cause of the ball players death. The court focused on the chain of events that led to the ball player’s death. It concluded that the blood clot was “partial because the accident had to have played a role; no accident, no surgery or immobilization, hence no deep vein thrombosis or pulmonary embolism (blood clot).”

The court struck down the insurer’s arguments that the beneficiary had to prove that no other events played a role, and that the company had the “discretion to decide what evidence was sufficient to demonstrate a disability.” The court wrote that such burden of proof and discretion is illusory because it would give the insurance company unchecked carte blanche to decide whether to honor its contract.

Because the insurance company failed to make any plausible showing that the surgery, rather than the accident that necessitated the surgery, caused the basketball players death, the 7th Circuit Court of Appeals held that the judgment should have been in favor of the plaintiff beneficiary.