Pelkey v. General Electric Capital Assurance Co., 2002 ME 142

Summary

The Supreme Judicial Court of Maine held that an accident insurance policy was ambiguous regarding whether pre-existing medical conditions contributing to an accidental loss excluded coverage. Construing the ambiguity in favor of the insured, the court vacated the summary judgment for General Electric Capital Assurance Company and remanded for entry of judgment for Jack Dean Pelkey. A dissent would have affirmed, concluding that the policy's requirement that the loss result directly and independently of all other causes excluded coverage.

Holdings

1. An accident insurance policy containing a directly-and-independently-of-all-other-causes provision but no separate disease exclusion is ambiguous as to whether coverage is barred when a pre-existing disease or condition combines with an accident to produce the loss.
2. Because the policy lacked a disease exclusion and was ambiguous regarding the effect of Pelkey's pre-existing conditions, the policy had to be interpreted in favor of coverage for the loss of his leg.

Questions Presented

1. Whether the policy's requirement that a loss be due directly and independently of all other causes to accidental injury unambiguously excluded coverage when a pre-existing medical condition contributed to the loss.
2. Whether, in the absence of a separate disease exclusion, the policy's ambiguity had to be construed in favor of coverage for Pelkey's accidental loss.
3. Whether the Superior Court properly entered summary judgment for General Electric.

Disposition

reversed_and_remanded