Life Insurance Claim Denial

Life insurance attorneys will tell you that the language used in the insurance policy is important to determining coverage. An experienced Insurance Law Attorney will also tell you there are many ways of getting around some of the language in a policy.
Here is a case where the facts were bad but the case still serves as an example of how the courts interpret policy language. The style of the case is Douglas v. Southwestern Life Ins. Co. It is a Tyler Court of Appeals opinion that was issued in 1964.
Here is some of the relevant information.
There were two policies, one in the amount of $50,000.00 and the other in the amount of $40,000.00, that were issued to Sterling B. Douglas in December, 1958 and May, 1960, respectively. To each of these policies was attached a supplementary contract captioned ‘Benefit for Death by Accidental Means’. Among other provisions under this caption the supplementary contract contains this provision:
‘BENEFIT. The Company hereby agrees, subject to the terms and conditions of this contract, that it will pay to the beneficiary designated in the policy Fifty Thousand Dollars in addition to the amount payable under the terms of the policy of it receives due written proof that while this contract was in force the death of the Insured resulted directly from bodily injuries effected exclusively and independently of all other causes through external, violent and accidental means and within 90 days from the date of accident which caused such injuries, of which, other than in the case of drowning or internal injuries revealed by an autopsy, there is a visible contusion or wound on the exterior of the body, provided such death did not result from any of the risks which are expressly excluded herefrom.’
The language is identical in both contracts sued upon except in one the amount is $50,000 and in the other $40,000.
The facts, about which there is no dispute, show that the named insured, Sterling B. Douglas, was involved in an automobile accident on June 4, 1961, in which he received serious and fatal injuries. Immediately upon being admitted to the hospital, he underwent surgery and was operated upon again twice in June, and once in August and September. He was in critical condition down to the date of his death. His physician, during most of the course of his hospitalization, considered it unlikely that he could survive. It was only because of the extraordinary medical measures taken by the medical staff that caused him to live as long as he did and had these measures not been taken he would have probably died within 90 days after the date of the accident. He died on October 2, 1961. This was 120 days after the accident in which he received fatal injuries causing his death. Within 90 days of the date of the accident the agent of the Company was notified and was told by the doctor and Mrs. Douglas that the insured would not and could not survive his injuries.
Southwestern paid ordinary benefits but denied liability for accidental death benefits under the supplementary contracts on the ground that the death of the insured within 90 days from the date of the accident was a condition precedent to any liability of appellee under the supplementary contracts. This suit followed, and both parties moved for a summary judgment. The court denied Douglas’s motion and sustained Southwestern’s motion.
This is a suit upon a written contract of insurance and in order for Douglas to recover she must bring herself within the coverage provided for in the contract. To construe the contract as not requiring death to occur within 90 days after the date of the accident would be to ignore the plain words of the policy. Until the conditions prescribed by the terms of the policy had been met there was no obligation on the part of Southwestern.
The policy did not provide for payment by reason of accidental death regardless of the date of death. Rather, the policy limited the payment of accidental death benefits to those that occurred within a 90-day period after the injury that caused death. As the court construed the contract, Southwestern promised payment of accidental death benefits if and only if the death of the insured resulted within 90 days of the accidental injury.
‘The doctrine followed by Texas courts which seems to be well supported by the authorities, is that: ‘The standard accident policies, in addition to the provision for indemnifying the insured, against the results of accidental injuries, generally provide for the payment of a certain sum in the event of his death being caused by accident, provided death occurs within a specified time (usually 90 days) after the occurrence of the accident; and provisions so limiting the time within which death must occur to render the insurer liable, have been held to be valid and binding, and there can be no recovery for the death of the insured if it occurs more than the prescribed time after the accident, although within the terms of the policy.’
The uncontroverted facts show that the accidental injury causing the death of the insured occurred on June 4, 1961, but that the insured did not die until October 2, 1961, approximately 120 days after the accidental injury.
This court had a few pages of additional reasoning but still upheld the summary judgement in favor of Southwestern.