Stroke is one of the leading causes of disability in the United States. There are different causes of a stroke, but head trauma can cause stroke, particularly if the stroke occurs shortly after the accident. When a stroke is caused, or arguably caused, by an accident, it can create complicated coverage issues under disability policies. This is because injuries from an accident are often covered, but stroke caused by illness is often excluded.
This leads directly to the “efficient primate cause” doctrine, which is the rule for determining if coverage exists in first party cases “‘when a loss is caused by a combination of a covered and specifically excluded risks.” (Julian v. Hartford Underwriters Insurance Company (2005) 35 Cal.4th 747, 750.) The efficient proximate cause has been described by the California Supreme Court as the “the ‘prime,’ moving,’ or ‘efficient’ cause of the accident.” (State Farm Mut. Auto Ins. Co. v. Partridge (1973) 10 Cal.3d 94, 104-105.) Under the efficient proximate cause doctrine, “the loss is covered if the covered risk was the efficient proximate cause of the loss’ . . .’” (Julian, supra, 35 Cal.4th at 750.)
Where a stroke follows an accident, the coverage question becomes whether the accident (a covered event) or the stroke (an excluded event) are the efficient proximate cause of the disability. The insurance company has the “burden of establishing that the efficient proximate cause of [plaintiff’s] loss was an excluded peril.” (Alex R. Thomas & Co. v. Mut. Serv. Cas. Ins. Co. (2002) 98 Cal. App. 4th 66, 76.) A recent California federal case held, in the context of a stroke exclusion, that “to avoid coverage . . ., Defendant must prove that [the insured’s] poor health, rather than the accident, was the ‘efficient proximate’ or ‘predominate’ cause of death.” (Sawyer v. Hartford Life and Accident Insurance Company (S.D. Cal. 2012) 2012 WL 353775, *8.)
Whether the stroke exclusion applies under the efficient proximate cause analysis where it follows a head trauma accident is usually a factual question. The proximity of time the stroke occurred in relation to the accident, the circumstances of the accident, the age of the insured, the health risks the insured posed for stroke (i.e., high blood pressure) are examples of factual issues relevant to the efficient proximate cause analysis where a stroke is involved in causing a disability following a head injury.
One of the challenges facing insureds who have had strokes and become disabled can face is loss of cognitive functions. This can make it difficult for them to offer evidence about what occurred pre-stroke to establish the efficient proximate cause of the disability. Nevertheless, the facts can be demonstrated based on other evidence, including witnesses to the accident and circumstantial evidence. The insurance company has a duty to investigate, analyze, and make a coverage decision based on the information available.
Insurers are often quick to deny coverage anytime a stroke is involved in a disability under a policy containing a stroke exclusion, without adequately analyzing the role an accident may have played in causing the stroke. If an insured has suffered a stroke following an accident, and the insurance company denies coverage based on a stroke exclusion, there may be a basis to challenge that decision under California law.