Fifth Circuit Affirms Denial of AD&D Coverage for Amputation Caused by Preexisting Comorbidities

In Byerly v. Standard Ins. Co., No. 20-40302, __F.App’x__, 2021 WL 364243 (5th Cir. Feb. 2, 2021), Gregory Byerly had diabetes, peripheral neuropathy, and peripheral arterial disease. He stubbed his toe and ultimately required a below-the-knee amputation of his leg. He applied for AD&D benefits from Standard Insurance Company, and Standard denied the claim on the ground that his preexisting conditions resulted in the need for the amputation. He passed away for reasons unrelated to the amputation and his wife brought suit on behalf of his estate.

The district court ruled in favor of Standard and the Fifth Circuit affirmed. AD&D benefits were not payable because there was no qualifying “loss,” even under de novo review. Here, the AD&D policy covers the loss of a foot so long as the loss was caused solely and directly by an accident and independent of all other causes. The amputation was caused, at least in part, by his diabetes and peripheral vascular disease. It is undisputed that Byerly’s comorbidities substantially contributed to his amputation.

The court rejected Plaintiff’s contention that the focus should be on what caused the “initial injury” to the toe. The court explained that “[t]he problem for Plaintiff is that the Policy places the focus not on the cause of the accident or initial injury but on the cause of the ‘loss.’” The loss is the amputation. Because the amputation was not caused solely and directly by an accident and independently of all other causes, the Policy does not provide coverage.

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