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• W284936302 abstract "Pelkey v. General Electric Capital Assurance Company, 804 A.2d 385 (Supreme Judicial Court of Maine--August 21, 2002) Jack Dean Pelkey had a history of diabetes and severe peripheral vascular leg disease. He also had insurance from General Electric Capital Assurance. When he fell and injured his left knee in April 1998, resulting in an incurable infection and amputation of the lower portion of the leg, it raised the coverage question of whether his was a covered accident or rather the result of other factors, placing the incident outside the scope of the coverage. GE undoubtedly thought it had written a pretty tight definition of in the policy and could thus avoid coverage when Pelkey was willing to stipulate that his prior medical problems were substantial contributing factors to his development of infection, septic arthritis, and osteomyelitis, and the eventual amputation. 804 A. 2d at 387. The parties even stipulated that the fall would not have resulted in amputation but for the contribution of the pre-existing disease and vascular problems. The GE policy at issue provided that coverage for accidental and defined injury as bodily that: (1) is caused by an that occurs while the policy is in force as to the Insured Person; (2) results directly in loss insured by the Policy; (3) creates a loss due, directly and independently of all other causes, to such accidental injury; and (4) occurs in the manner and under the circumstances described in the Descriptions of Hazards which apply. 804 A.2d at 386 (emphasis added). However, the policy did not have a specific exclusion for pre-existing diseases or conditions. Rather, the insurer sought to exclude these in situations where they played a contributing role in the damage caused by an such as a fall. A split (4-3) Supreme Judicial Court of Maine found the definition and its attendant exclusionary language insufficiently clear to defeat Pelkey's claim for coverage. According to the Court majority, the policy language was sufficiently ambiguous to provide Pelkey with the benefit of the general rule that ambiguities in an insurance policy (like any other contract) are construed against the drafter (usually the insurer) and in favor of the nondrafting party (usually the policyholder). The dissenters concluded that the policy language was sufficiently clear even though it did not specifically excluded disease-related or pre-existing condition--driven from coverage. According to the dissent, the parties' stipulations place Pelkey's circumstances squarely outside the language of the contract that permits recovery only when the loss is due, 'directly and independently of other causes' to the accidental 804 A. …" @default.
• W284936302 created "2016-06-24" @default.
• W284936302 creator A5068397957 @default.
• W284936302 date "2003-03-01" @default.
• W284936302 modified "2023-09-27" @default.
• W284936302 title "Accident Policy without Explicit Disease Exclusion Ruled Too Ambiguous to Exclude Coverage for Infection Resulting from Fall in Combination with Pre-Existing Diabetes and Cardiovascular Disease. (Recent Court Decisions)" @default.
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