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The “Substantialy Contributing” Test: Insurance Companies Don’t Always Win

Substantialy Contributing Test AD&D Claims

In an earlier post, we took a first look at how courts treat pre-existing medical conditions when considering whether to award Accidental Death & Dismemberment (AD&D) benefits to plaintiffs. We pointed out that different courts have treated this question differently. Some will disqualify a plaintiff from benefits only if the pre-existing condition “directly and independently of all other causes” caused a death or dismemberment. Other courts will disqualify one from benefits if the pre-existing condition “substantially contributed” to the loss. The Eleventh Circuit Federal Appeals Court which governs Florida follows the “substantially contributed” test. Our first article might lead one to believe that Florida policyholders have long-shot odds of winning their AD&D case. This is not true. AD&D claimants do have a fighting chance as long as they retain experienced counsel familiar with case law in this specialized area.

Take for example the decision in Dowdy v. MetLife, a Ninth Circuit Court case, that has applicability in Florida based on its reasoning. The plaintiff in Dowdy was severely injured in a car accident and when persistent infections set in his left leg was ultimately amputated below the knee. His insurance company denied AD&D insurance benefits claiming that pre-existing diabetes substantially caused or contributed to the loss of limb. The District Court agreed with the carrier and denied benefits but the Appeals Court reversed and awarded those benefits finding that the insurance company fell short of sufficient proof. Some of the Court’s observations in making that decision would undoubtedly help any plaintiff in a similar situation. For instance, the Court found that a pre-existing condition must be more than merely a contributing factor to constitute being a “substantial contributing factor”. Moreover, the Court noted that a “pre-disposition” to injury alone, whether it results from congenital weakness or from previous illness or injury, does not necessarily amount to a substantial contributing cause.

Specifically, in the Dowdy case, the Court noted that a deep leg infection was “related to the original injury” and that the evidence failed to show that diabetes was a substantial contributing factor. The Court ruled in the Plaintiff’s favor.

The lesson to be learned in these and other cases is this: don’t try to do this yourself. You need to retain an attorney familiar with the standards of proof and case law governing AD&D cases. Similarly, you shouldn’t just hire any attorney. In an age of specialization AD&D law is its own body of law. Find an attorney with AD&D expertise and experience.

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