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Home > Blog > Ninth Circuit Affirms Denial of AD&D Benefits Due to Substantial Contribution of Preexisting Medical Condition

Ninth Circuit Affirms Denial of AD&D Benefits Due to Substantial Contribution of Preexisting Medical Condition

In Earle v. Unum Life Ins. Co. of Am., No. 20-55868, 2021 WL 4871785 (9th Cir. Oct. 19, 2021), a short unpublished opinion, the Ninth Circuit affirmed the district court’s determination that Unum Life Insurance Company of America correctly denied Plaintiff-Appellant Earle’s claim for accidental death and dismemberment (“AD&D”) benefits for the loss of sight in her right eye on the basis that it was not the result of an accidental bodily injury. The AD&D policy excludes payment for losses caused by or contributed to by disease of the body or diagnostic, medical, or surgical treatment. Walker Earle v. UNUM Life Ins. Co. of Am., No. CV 19-2903-JFW(AFMX), 2020 WL 4434951, at *13 (C.D. Cal. July 23, 2020). Unum determined that Plaintiff’s preexisting vitreomacular traction (“VMT”) substantially contributed to her vision loss, rather than the vision loss being caused by a fall while she walked up a flight of stairs.

The court found that the district court correctly determined that the exclusionary clause was conspicuous and as such, the “substantially caused” standard applies. That is, recovery of benefits would be barred if a preexisitng condition “substantially caused” or “substantially contributed” to the loss. The court found that it was not clearly erroneous for the district court to determine that “Earle could have developed a macular hole even without her March 15, 2017 fall, and conversely, that she would not have developed a macular hole without the preexisting VMT.” The court did not reach the issue of the standard of review, finding that even if the district court should have applied de novo review, rather than abuse of discretion review, “the district court’s conclusion that Earle’s preexisting VMT substantially contributed to her vision loss is unaffected.”

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