Yow v. American Home Assurance Co.

606 F. Supp. 3, 1979 U.S. Dist. LEXIS 10052
CourtDistrict Court, E.D. Virginia
DecidedSeptember 4, 1979
DocketCiv. A. No. 78-0774-R
StatusPublished
Cited by1 cases

This text of 606 F. Supp. 3 (Yow v. American Home Assurance Co.) is published on Counsel Stack Legal Research, covering District Court, E.D. Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Yow v. American Home Assurance Co., 606 F. Supp. 3, 1979 U.S. Dist. LEXIS 10052 (E.D. Va. 1979).

Opinion

MEMORANDUM

WARRINER, District Judge.

This is a diversity action grounded upon two interrelated theories of recovery. Plaintiff asserts his right to recover contractual benefits under an accidental dismemberment insurance policy issued by defendant. He also seeks tort recovery and punitive damages for defendant’s refusal to pay the contractual sum due. After extensive discovery the parties concluded there were no material issues of fact as to either basis for liability and by pre-trial order they submitted all questions of law and fact to the Court on the record. The question of damages, if liability be found, was reserved for a jury trial.

Plaintiff is a Methodist minister who had been subject to dizzy spells for some time. Despite this disability and despite his fear of injury, he was operating his woodworking saw on the afternoon of 16 March 1976. He was afflicted with a dizzy spell while operating the saw, fell against the saw, and severed his left hand above the wrist. Mr. Yow had a policy of insurance with defendant which provided for certain payments upon severance of his hand. He promptly notified defendant of the accident and submitted the requisite proof of loss. Proof of loss was received by defendant on 19 April 1976.

The claim was handled by one Michael Squilante, supervisor in defendant’s New York office. He promptly initiated an in[4]*4vestigation into the loss seeking to find, among other things, whether the injury might have been self-inflicted. The investigation showed no evidence that the loss was self-inflicted and this aspect of the matter received no further attention.

Defendant next sought further information as to the nature of the precedent dizzy spells. At the same time he sought a medical opinion as to whether there was “an underlying disease or illness responsible for the dizzy spells.” The medical opinion, based on incomplete and less than adequate information furnished by Squilante, was that the fainting spell was “the result of pre-existing disease.”

Having obtained further medical information, Squilante sought additional medical advice from the company’s medical advisor. Again the advisor reported that “abnormality in the brain” would account for the dizzy spells. The medical advisor’s evaluation of the medical reports sent to him improperly interpreted a “suggestion” of brain abnormality as a diagnosis of abnormality. In fact, the examining physician had found that the dizzy spells were “transient functional rather than stable or chronic____”

Having thus obtained erroneous medical advice, Squilante sent a memorandum to a New York lawyer, outside counsel, asking his legal opinion on the following question:

John, This is a claim for dismemberment benefit. Loss of left hand, $150,000. Enclosed is our entire claim file. He had dizzy spell while using a power saw at home. Fell into saw and severed hand, one centimeter proximal to distal end of radius taken to hospital and hand re-attached or re-implanted. (This is the non-dominant hand) with satisfactory results. If all goes well, MD says the most he will be able to do is open and close the hand and pick up large objects — could never use it for fine movement.
Please review question of accident directly and independently of all other causes and whether he has sustained loss of hand under the policy provisions. Regards, M.A. Squilante.

This request for a legal opinion was sent on 18 May 1976. On 14 July 1976 counsel reported by telephone to the company that his opinion was “leaning towards this being payable.” In response to this report the company set up a 50% reserve.

In his written opinion of 15 July 1976 outside counsel noted that there was no case in point in Virginia and that there was a diversity in the precedents in the several states. He also noted that:

Virginia is a rather conservative State as to accidental loss. While there is no case that holds that a dizzy spell which causes the fall will prevent an accidental loss, the cases that are on the books in Virginia are quite conservative.
The cause of the fainting spells is important. If the spells themselves are tantamount to a disease or if they are clearly caused by disease, the general rule is to the effect that the injury received in a fall caused by disease is not an accident directly and independently of all other causes. Not every State will follow this line of reasoning. Since Virginia has no case on point all we can do is look at the general rule.
It is my belief that Virginia is quite conservative and that we would have a better than even chance of having them follow the general rule. Our chances would be enhanced, however, if we could determine that the fainting spells were caused by disease rather than a momentary indisposition or some temporary weakness. In all events, this case will have high settlement value. Since there is no case in point the fact that the injury was received as a result of a fainting spell should be sufficient to enable the company to properly defend. It will present a case of novel impression in Virginia. As much information as possible should be obtained concerning the nature and origin of the fainting spells.

Despite this suggestion by outside counsel, Squilante made no further effort to [5]*5determine whether the recurring dizzy spells were a result of “disease” though the treating physicians had by this time concluded the dizzy spells were not the result of disease.

Having received the advice of counsel, Squilante and his superior met on 6 August 1976 and determined that they should deny the claim and prepare to defend it. Accordingly, on 11 August 1976 Squilante wrote Mr. Yow, called his attention to the fact that any loss under the policy must result “directly and independently of all other causes” and advised him that no benefits were payable under the policy terms.

Approximately a month later Mr. Yow responded by saying that he was “shocked” that his claim was denied. He offered to provide any further information and requested a reconsideration. Squilante did not receive this letter but on 28 January 1977 Mr. Yow wrote again specifically stating that “no evidence of disease was found.” He requested a prompt reconsideration and advice. Squilante replied on 17 February 1977 stating he had “no alternative but to reiterate our company’s position as set forth in our letter of denial of August 11, 1976.”

Despite the fact that Mr. Yow’s letter of 28 January 1977 specifically pointed out that no disease had been found, and dispite the fact that outside counsel considered that disease vel non was an “enhancing” factor, Mr. Squilante did not re-refer the matter to outside counsel for further evaluation. Nor did he point out to Mr. Yow that the denial was based specifically upon the assumption that the dizzy spell was a result of a pre-existing disease.

No further activity between the parties took place until after an action'on the policy was filed on 15 March 1978 in the United States District Court for the Western District of Virginia.1 Upon the filing of the action defendant offered $90,000.00 in full settlement. This offer was rejected. Since this Court is both trier of law and fact, further offers at settlement, if any, have not been communicated to the Court.

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606 F. Supp. 3, 1979 U.S. Dist. LEXIS 10052, Counsel Stack Legal Research, https://law.counselstack.com/opinion/yow-v-american-home-assurance-co-vaed-1979.