‘Exclusive Result’ Clause at Issue in Appeals Court Decision

Sun Life is staring at a $92,000 benefit payout after the company could not convince a federal appeals court that complications from surgery were to blame in the death of 31-year-old Jeremy Prather.

Sun Life argued that the blood clot that killed Prather on Aug. 6, 2013, resulted from surgery to repair a torn Achilles tendon and not from the “exclusive result” of tearing his tendon playing basketball in July 2013, three weeks before he died.

But the U.S. Court of Appeals for the 7th Circuit in Chicago found the insurance company’s argument unconvincing.

“Since the accident alone — the rupturing of the tendon — may well have caused the blot clot that killed Prather, the insurance company had to present some evidence that the surgery had been a cause of Prather’s death — and it presented none,” the court found.

“All the evidence shows is that his death followed both the surgery and the accident that preceded the surgery,” the three-judge panel wrote in a six-page decision.

Prather’s beneficiary Lee Ann Prather sued Sun Life after the company denied the benefit payment because Prather’s death, the company argued, wasn’t the exclusive result of an accident, but instead was due in some way to the surgery.

A district court agreed and found in favor of the company.

The appeals court noted that medical literature is filled with incidents where an accident by itself – such as a tendon tear – is enough to create a fatal blood clot and thereby inflict bodily injury without any other cause. This would trigger the benefit in the accident death and dismemberment policy.

Prather even complained of swelling to his lower left leg and sensitivity to his left calf a day before he went into surgery on July 22, 2013, the court also found.

Sun Life’s insurance accidental death and dismemberment policy covering Prather limited coverage to bodily injury from accident and independently of all other causes. The company interpreted that to require the beneficiary to disprove any possible alternative cause of death.

But if that were the case, then “it would give the insurer carte blanche to reject coverage in a case in which an accident is a conceded cause of death,” the court found.

On July 16, 2013, Prather tore his left Achilles tendon playing basketball and was scheduled for surgery shortly after visiting an orthopedic surgeon.

A day before his July 22 surgery he complained of swelling to his lower left leg and that his left calf was sensitive and warm to the touch.

Four days after a follow-up visit with the surgeon on Aug. 2, Prather collapsed at work and died of a clot to the lung.

InsuranceNewsNet Senior Writer Cyril Tuohy has covered the financial services industry for more than 15 years. Cyril may be reached at [email protected].
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Cyril Tuohy is a writer based in Pennsylvania. He has covered the financial services industry for more than 15 years. He can be reached at [email protected].