This is a Texas diversity case between Aetna Life Insurance Company and Mrs. Judith Sekel, involving the construction of an exclusion clause as applied to accidental death benefits under Aetna combined group life and accidental death policies in which Mrs. Sekel is the named beneficiary. The issue presented for our consideration is whether the language of the exclusion clause bars recovery of accidental death benefits respecting a death, a functionally closely related significant contributing factor or cause of which is a "bodily infirmity" or "disease," but whose more immediately precipitating and proximate cause is accidental bodily injury. The district court, ruling on cross-motions for summary judgment, held for the beneficiary that it did not. Concluding that the exclusion clause in the policy does bar recovery, we reverse.

On August 12, 1978, Mrs. Sekel's late husband, Richard Sekel, insured under Aetna's combined group life and accident policies issued in 1973 to his employer under a single certificate, fell to the floor at his home and sustained a "severe" blow to his head, which resulted in his death within approximately one hour following the fall. Mr. Sekel had a "severe atherosclerotic and hypertensive cardiovascular disease" which the autopsy report, completed by three physicians, concluded had probably caused his fall. The parties stipulated that this report and the death certificate "accurately and correctly set forth" "the facts regarding the cause of death." The report states:

"In our opinion Richard Sekel, a 62 year old white male, died from severe head trauma, which included fracturing of the base of the skull and bruises of the brain surfaces. The initiating event was probably an arrhythemia (failure of the heart to beat properly) secondary to the victim's very severe hypertensive and atherosclerotic cardiovascular disease (high blood pressure and hardening of the arteries). Therefore, the victim probably 'passed out' because of his natural disease processes and subsequently struck his head when he fell."

The foregoing is the only relevant evidence as to the cause of death. Mrs. Sekel, as beneficiary, received benefits from Aetna for the life insurance coverage, but was denied them under the accident coverage. The accident benefits coverage clause states that Aetna will pay the stipulated benefits, if Mr. Sekel suffers a "bodily injury caused by an accident and as a direct result of such injury and, to the exclusion of all other causes, sustains within not more than ninety days ... any of the losses [covered]." Aetna does not expressly contest that Mr. Sekel's accidental death falls within these terms. It maintains, however, that the exclusion clause in the policy precludes Mrs. Sekel's recovery of accidental death benefits. This clause states:

"The insurance provided under this Title does not include, and no payment shall be made for, any loss resulting from any injury caused or contributed to by, or as a consequence of, any of the following excluded risks, even though the proximate or precipitating cause of loss is accidental bodily injury:

"(a) bodily or mental infirmity; or

"(b) disease...."

The sole issue for our consideration is whether this exclusion clause bars Judith Sekel's accidental death benefit recovery.

The coverage clause in the Aetna policy is similar to those in many other accidental death or disability policies, which typically provide that an insured can only recover if the loss is "directly and independently" or "independently and exclusively" caused by an accident. In Texas and most other jurisdictions these clauses have been construed to preclude recovery where disease or bodily infirmity is a concurrent proximate cause of death. Mutual Benefit Health & Accident Association v. Hudman, 398 S.W.2d 110, 115 (Tex.1965); 10 G. Couch, R. Anderson, & M. Rhodes, Couch on Insurance 2d, Sec. 41:75 at 113-14 (rev. vol. 10, 1982); and see 1B Appleman, Insurance Law & Practice Sec. 393 at 64-73 (rev. vol. 1B 1981). Where such disease is found to be a "remote" cause, however, courts have not barred recovery. Stroburg v. Insurance Company of North America, 464 S.W.2d 827, 829-31 (Tex.1971); Appleman, Sec. 393 at 81; Couch, Sec. 41:79-80 at 128-33.

Many policies also contain an exclusion clause which specifically disallows recovery where disease caused or contributed to the loss. In Stroburg v. Insurance Company of North America, the Texas Supreme Court recognized two types of exclusion clauses, those which excluded coverage only when disease was a proximate cause, and those which also excluded it when disease was a more remote cause, of the loss. In the first category was the clause presented in that case which provided that "[t]his policy does not cover loss caused by or resulting from any one or more of the following: ... [i]llness, disease ... bodily infirmity...." The court cited as an example of the second type those clauses which included language excluding liability if disease or bodily infirmity contributed "directly or indirectly" to the loss. 464 S.W.2d at 831-32. We must decide whether the Aetna exclusion clause falls into this second category, effectively excluding coverage where disease, though a functionally closely related significant contributing factor or cause is nevertheless neither a concurrent proximate nor the most immediately precipitating cause of loss, or into the first category, excluding coverage only where disease is at least a concurrent proximate cause.

In doing so we are guided by the principles which govern the construction of insurance contracts under Texas law. These principles were well summarized in Glover v. National Insurance Underwriters, 545 S.W.2d 755, 761 (Tex.1977):

"[E]xceptions and rules of limitation will be strictly construed against the insurer. Further, we must adopt the construction of an exclusionary clause urged by the insured as long as that construction is not itself unreasonable, even if the construction urged by the insurer appears to be more reasonable or a more accurate reflection of the parties' intent. [Citations omitted.] On the other hand, we recognize that these rules of construction will be applied only when the language of the policy is such that it may reasonably be given one of several constructions. [Citation omitted.] In other words, the plain language of an insurance policy, like that of any other contract, will be given effect when the parties' intent may be discerned from that language. But when the language of an insurance contract is ambiguous, that is, is subject to two or more reasonable interpretations, then that construction which affords coverage will be the one adopted."

We now examine the words of the Aetna policy to determine how these principles apply. The exclusion clause in this policy denies coverage for accidental death benefits respecting "any loss resulting from any injury caused or contributed to by, or as a consequence of, any of the ... excluded risks, even though the proximate or precipitating cause of loss is accidental bodily injury."1 This language contemplates a situation where "the proximate or precipitating cause of loss" is accidental bodily injury, and makes clear that, "even though" the accidental injury is the proximate or precipitating cause, if disease or bodily infirmity is also a contributing factor or cause, there is no coverage. Since the exclusion clause by its terms is applicable when the proximate or precipitating cause of loss is an accidental injury, necessarily implicit in its meaning is that other contributing factors or causes which the policy excludes (e.g., "bodily or mental infirmity" or "disease") need not be concurrent proximate or as immediately precipitating causes for the exclusion to have effect. Thus, a loss, a functionally closely related significant cause or contributing factor of which is a noncovered risk, is excluded from the policy's accidental death benefits even though a covered risk is the proximate and more immediately precipitating cause of the loss.

The exclusion clause is clear and unambiguous in conveying this meaning. As such, the principle of construing insurance contracts strictly against the insurer does not apply, Southern Life and Health Insurance Co. v. Simon, 416 S.W.2d 793, 795 (Tex.1967); Gulf Atlantic Life Insurance Co. v. Disbro, 613 S.W.2d 511, 512 (Tex.Civ.App.--Beaumont 1981, no writ), and we must give the language of the policy its plain meaning. Argonaut Southwest Insurance Co. v. American Home Assurance Co., 483 F.Supp. 724, 727 (N.D.Tex.1980); Vanguard Insurance Co. v. Stewart, 593 S.W.2d 736, 739 (Tex.Civ.App.--Houston [1st Dist.] 1979), aff'd, 603 S.W.2d 761 (Tex.1980); American-Amicable Life Insurance Co. v. Lawson, 419 S.W.2d 823, 826 (Tex.1967); Republic National Life Insurance Co. v. Spillars, 368 S.W.2d 92, 94 (Tex.1963).

We conclude that the Aetna exclusion clause is of the second type described in the Stroburg decision, and coverage is barred when a risk excluded by the policy is a functionally closely related significant cause or contributing factor of the loss even though a covered risk is the proximate and more immediate precipitating cause. A contrary interpretation disregards the clear and unambiguous meaning of the exclusion clause, especially its "even though" phrase. Mr. Sekel's heart condition, the "natural disease processes" of which caused him to pass out and immediately fall, striking his head and resulting in his death within approximately an hour, certainly bore a functionally close and significant causal or contributory relationship to his death. This is not an instance where for want of a nail the rider was lost.2 Nor was the heart condition "dormant and insubstantial" or "transient"; rather, it was an obviously longstanding "very severe ... disease," something obviously not typical even of the man who is "neither 'an Apollo or Hercules.' " See Mutual Benefit Health & Accident Association v. Hudman, 398 S.W.2d at 114. In the common understanding of mankind, this very severe disease was a cause or contributing factor of Mr. Sekel's death, or his death a consequence of the disease, in much the same sense that an accidental shove off a precipice would be regarded as a cause of or factor contributing to the death of a victim who plunged to his destruction on the rocks below.3 All that stands in the way of completing the causal, contributory or consequential connection between disease and death is that the otherwise accidental blow to the head constitutes the more immediately precipitating and proximate cause of death. Yet, the "even though" phrase informs us that the disease's causative or contributory role is to be given exclusionary effect "even though the proximate or precipitating cause of loss is accidental bodily injury."

This interpretation is also compelled by another principle of construction, for, where reasonably possible, we must not construe the policy to leave specific provisions without meaning or effect. Liberty Mutual Insurance Co. v. American Employers Insurance Co., 556 S.W.2d 242, 245 (Tex.1977); First National Bank of Midland v. Protective Life Insurance Co., 511 F.2d 731, 734 (5th Cir.1975); cf. Martindale Lumber Co. v. Bituminous Casualty Corp., 625 F.2d 618, 623 (5th Cir.1980). The opinions in such Texas cases as Stroburg, 464 S.W.2d at 831-32, and National Life & Accident Insurance Co. v. Franklin, 506 S.W.2d 765, 768 (Tex.Civ.App.--Houston [14th Dist.] 1974, writ ref'd n.r.e.),4 clearly reflect that exclusion clauses, not containing any language comparable to that of our clause's "even though" phrase but in all other respects being similar to it, are considered sufficient to preclude accidental death recovery when disease is a concurring proximate cause of death, notwithstanding that accidental bodily injury is also a proximate cause of the death. See also Hudman, 398 S.W.2d 110 at 111, 115. In other words, the present exclusion clause, without the "even though" phrase, would clearly preclude accidental death benefit recovery for any death of which disease was a concurrent proximate cause. Accordingly, the "even though" phrase would be rendered meaningless unless it operated to preclude recovery in at least some instances where the causal or contributory relationship between death and disease was less than proximate.5

Although no Texas law decisions have made a direct holding on the "even though" phrase in the type of exclusion clause before us, our interpretation of it is supported by the construction given it by this and other courts.6

In Huff v. Aetna Life Insurance Company, 120 Ariz. 548, 587 P.2d 267 (Ariz.App.1978), an Arizona court interpreted an Aetna policy containing the same language in the context of a claim with analogous facts. In that case the insured, Mr. Huff, suffered a heart attack while driving, which caused him to lose control of his automobile. He had an accident and was killed as a result of injuries he received. The heart attack alone caused his accident and the injuries from the accident alone caused his death. The court, relying on the exclusion clause language, "... even though the proximate or precipitating cause of the loss is accidental bodily injury," held that it precluded coverage for Mr. Huff's death, stating:

"... [T]he Aetna policy in question goes beyond the 'caused, contributed to by, or as a consequence of' language by concluding:

'... even though the proximate or precipitating cause of loss is accidental bodily injury.'

"Here, Aetna has clearly indicated its exclusion is applicable to both proximate and remote causes such as Mr. Huff's unfortunate heart attack.... [T]o hold otherwise would effectively read this latter clause out of the policy." Id. 587 P.2d at 270-71.7

In Britt v. Travelers Insurance Co., 556 F.2d 336 (5th Cir.1977), modified, 566 F.2d 1020 (5 Cir.1978), this Court, applying Mississippi law, reached the same result. In that case, the proximate cause of the insured's death was exposure, though the insurance company (Travelers) introduced evidence that his preexisting bodily infirmities had contributed to his death as a nonproximate cause. The Court, interpreting an exclusion clause very similar to Aetna's, stated that "Travelers' policy ... prohibit[s] recovery when the disease contributes to the death even though the latent or dormant disease was precipitated and made active by the accident," that is, when it is a nonproximate cause. Id. at 343.8 We find these holdings of Huff and Britt to be persuasive here.

Mrs. Sekel makes two additional arguments. The first is that the exclusion clause cannot reach "remote" causes because it does not contain the words "directly or indirectly." For this assertion she relies upon Stroburg, which noted that policies containing a provision "excluding liability if disease or bodily infirmity contributed 'directly or indirectly' to the insured's injuries or death" reached cases where disease was a cause, whether proximate or more "remote." The court quoted with approval the case of Russell v. Glens Falls Indemnity Co., 134 Neb. 631, 279 N.W. 287 (1938), which stated:

" 'It seems reasonably clear that a policy with the phrase 'resulting directly, independently and exclusively' refers to the efficient, substantial and proximate cause of the disability at the time it occurred. On the other hand, a policy which also has the phrase 'wholly or partly, directly or indirectly, from disease or mental or bodily infirmity' refers to another contributory cause, whether proximate or remote.' 279 N.W. 291." 464 S.W.2d at 831.

Mrs. Sekel seeks to elevate the words "directly or indirectly," quoted in the Stroburg and Russell decisions, to sanctimonial status, and construe them as the only means by which Aetna can exclude losses nonproximately caused or contributed to by or consequent on uncovered risks. The Russell case, however, noted that a clause with the words "directly or indirectly" "or a like phrase " will have this effect. Id. 279 N.W. at 292 (emphasis added). We must give to the words of an insurance contract their plain meaning, Argonaut Southwest Insurance Co. v. American Home Assurance Co., 483 F.Supp. at 727; Vanguard Insurance Co. v. Stewart, 593 S.W.2d at 739; American-Amicable Life Insurance Co. v. Lawson, 419 S.W.2d at 826; Republic National Life Insurance Co. v. Spillars, 368 S.W.2d at 94, and we thus decline to hold that the phrase "directly or indirectly" is an indispensable term of art when Aetna has used in its exclusion clause language equally clear in its import.

Mrs. Sekel's second argument against our result is that in spite of the apparent meaning of the phrase "even though the proximate or precipitating cause of loss is accidental bodily injury" in the exclusion clause, it was inserted by Aetna for an entirely different purpose. That purpose, according to Mrs. Sekel, was to make the exclusion clause effective in denying coverage where disease was actually a concurring proximate cause with an accident. To bolster this argument Mrs. Sekel cites a law journal article, Bronson & Fields, The Problem of Concurrent Causation of Death Under Health and Accident Policies: A Solution Found?, 32 Insurance Counsel Journal, 241 (1965), which suggests that the employment of the "even though" phrase in the exclusion clause of an accident policy is for the purpose of preventing recovery when disease is actually a concurrent proximate cause of death. Past decisions allowing recovery in those circumstances, Mrs. Sekel argues, have troubled insurance companies such as Aetna, and provoked it to insert the "even though" phrase. Both Mrs. Sekel and the cited law journal article suggest that such decisions represent the majority rule among states and that it was at one time the rule in Texas. According to Mrs. Sekel, however, the law in Texas unexpectedly developed with Hudman to preclude liability, notwithstanding the absence of an "even though" phrase or comparable exclusionary wording, if a disease was a concurring proximate cause, and now Aetna is attempting to extend the application of this phrase beyond its original purpose, by using it to bar claims in which disease was a "remote" cause, while it was intended only to bar ones in which disease was a concurrent cause.9

The appellee's theory is not convincing. It is premised on the contention that insurers have regularly been held liable on accident policies of the first type described in Stroburg when a proximate cause of loss was disease. However, where policies provide that an accident must "directly and independently" be the cause of a loss, the general rule is that if disease is a concurrent proximate cause, the insurance company is not liable. Couch, Sec. 41:75 at 113-14; Appleman, Sec. 393 at 69-73. Couch states that: "When the facts are such that neither the accident nor the pre-existing disease can be isolated as the proximate cause, and it is concluded that both combined or operated to produce the harm, the insurer is not liable." Couch, Sec. 41:75 at 113-14.

This general rule is also the law in Texas. It was clearly set forth in 1965 in Hudman, and as that decision demonstrates, this rule has been controlling in Texas for many years. 398 S.W.2d 110 at 113.10 One case, Pyramid Life Insurance Co. v. Alexander, 337 S.W.2d 813 (Tex.Civ.App.--Texarkana 1960, writ ref'd, n.r.e.), approved a jury instruction inconsistent with the general rule reaffirmed in Hudman and was specifically disapproved of in that decision. That instruction stated:

"[Y]ou are instructed that death resulting from accidental bodily injury directly and independently of all other causes occurs when death is the reasonable and natural consequence of such accidental bodily injury, as the term has been defined, and but for which, such death would not have occurred. Such death can occur from accidental bodily injury directly and independently of all other causes even though disease may have been present as a secondary cause thereof." Id. at 814-15.

The law review article cited above seized on the instruction's use of a "but for" test to argue that it permits liability even where disease is a concurrent proximate cause with an accident, because loss would not have occurred "but for" the accident. Bronson & Fields at 242. The Hudman court also criticized the application of a "but for" test in the Pyramid case because it could permit recovery where disease was a concurrent proximate cause in an accidental death. Hudman, 398 S.W.2d at 113. In spite of this attention, Pyramid had not established a rule in Texas contrary to the majority position.11

Thus, Mrs. Sekel's claim that the phrase "even though the proximate or precipitating cause of loss is accidental bodily injury" was designed to prevent recovery in situations where disease was a concurrent proximate cause, is without force because its underlying assumption--that courts in such situations were allowing recovery--is not valid under Texas law, or in most other jurisdictions.12 We conclude that the purpose of this clause was to bar recovery in cases where the insured's death was caused or contributed to by or a consequence of a noncovered risk such as disease, even though an accidental injury was the proximate or precipitating cause of death, so that, accordingly, the causal, contributory or consequential relationship between the disease and death was not proximate.

Accordingly, the judgment below is reversed.

REVERSED.