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Court Upholds Aetna’s Denial of Accidental Death Benefits Under Intoxication Exclusion

In Jordan Harper v. Aetna Life Insurance Company, (Aetna), Plaintiff’s husband, Douglas Harper, died on December 31, 2017, in a single car accident to which there were no witnesses. The accident report noted there were no skid marks or any indication the driver of the car took any evasive action. 

The death certificate showed the cause of death as “multiple blunt force injuries.” The autopsy report and the toxicology report showed that Mr. Harper was under the influence of both amphetamine and methamphetamine at the time of his death. Although he had a prescription for the medication, Adderall, which is an amphetamine, methamphetamine is an illegal Schedule II controlled substance. The toxicology report also indicated that the decedent had more amphetamine in his system that he would if he had only taken the Adderall according to the prescribed dose.

At the time of decedent’s fatal accident, he was employed by Integrated Services Company (Inserv) which, as part of its employee benefit plan (Plan), provided its employees with an accidental death and personal loss (ADPL) insurance policy. The policy was issued by Aetna which acted as both the administrator and payer of the claims. 

One clause of the policy specifically stated that:

“No benefits are payable for a loss caused or contributed to by: Use of alcohol or intoxicants or drugs, while operating any form of a motor vehicle whether or not registered for land, air or water use. A motor vehicle accident will be deemed caused by the use of alcohol, intoxicants or drugs if it is determined that at the time of the accident you or your covered dependent were: Operating the motor vehicle while under the influence of an intoxicant or illegal drug; or Operating the motor vehicle while under the influence of a prescription drug in excess of the amount prescribed by the physician…”

Plaintiff, the wife of the decedent and also an Inserv employee, was the beneficiary of her husband’s ADPL policy. When she filled a claim for the death benefits, Aetna denied her claim on the grounds that the intoxication exclusion applied. Her administrative appeal was denied so she filed this ERISA lawsuit in the U.S. District Court for the Northern District of Oklahoma. She raised several issues, primarily that Aetna abused its discretion in denying her claim for death benefits.

The Court disagreed with Plaintiff and found it reasonable for Aetna to deny death benefits to her. The Court held that the plain language of the policy made it clear that since the toxicology report made it clear that her husband had amphetamine and methamphetamine in his blood stream at the time of the accident, the intoxication exclusion applied and Aetna did not abuse its discretion, and its decision to deny her death benefits was not arbitrary and capricious.

Application of the Intoxication Exclusion

The Court noted that “In determining whether Aetna abused its discretion in denying plaintiff’s claim, the Court must consider whether it was reasonable for Aetna to find that decedent was under the influence of intoxicating drugs at the time of his death.” In making its decision the Court reviewed the same items Aetna reviewed in determining the intoxication exclusion applied and Plaintiff was therefore not entitled to death benefits. The documents included, among others:

Plaintiff argued that relying on the toxicology report alone was an abuse of discretion and that it should have hired an expert to analyze the report. She also argued that Aetna should not have relied on the claims analysis and registered nurse who reviewed the toxicology report and used a wrong chart in determining the blood levels of the decedent.

The Court found that it didn’t matter what chart was used, the toxicology report showed that “decedent tested positive for methamphetamine” which is a Schedule II illegal drug.

The Court held “not only did Aetna act reasonably in its decision to deny life insurance and basic and dependent ADPL benefits, but also its decision is supported by substantial evidence based on the intoxicant and illegal drugs exclusion.”

This case was not handled by our firm, but we believe it can be instructive for those who are wrestling with their insurance company over a claim for death benefits and the company is claiming it has no obligation to pay benefits under an intoxication exclusion. If you have questions about this case, a question about collection of accidental death benefits, or a question about a claim for short-term or long-term disability (LTD) benefits, contact one of our attorneys at Dell & Schaefer for a free consultation.

You can read about Aetna disability claims on this page.

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FAQ

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We represent Aetna clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Aetna disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Aetna. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Aetna.

How do you help Aetna claimants?

Our lawyers help individuals that have either purchased a Aetna long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Aetna:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Patricia T. (Florida)

If you think the insurance company is going to be FAIR, you are WRONG! Get an attorney, I recommend Dell & Schaefer. They entered my life approximately 4 years ago. I was in the mid years of my life, moving along routinely finishing up my 29th year of continuous employment as a professional Acute Care Registered Nurse, looking ahead to planning my future and possibilities ahead of me. I had planned to work at least another 15 years and maybe more if I could. I was hitting the peak of my value in the health system that employed me and I loved my job. Income was never an issue for me, as in my profession I could always find work and make as much income as I needed raising a family etc… But just incase, my father always taught me to have a safety net. So every year for 29 years, around benefit time I would fill out the forms and check the boxes for STD and LTD and pay the monthly dues for those policies in case I would ever need them, never expecting to use them. Well life had other plans for me.

My illness began slowly, I made adjustments to my work schedule and life schedule hoping that would allow me to stay employed. I didn’t want to give up the money, my benefits, the years experience I had, the value I had to contribute etc… That lasted for about a year and half then suddenly my body just couldn’t do it anymore. My illness exacerbated, necessitating me to leave work. I went out on my STD policy and initially Aetna the carrier of the policy was cooperative and approved my claim. After several months when I didn’t improve my STD policy was over and it was time to begin my LTD. At this point Aetna suddenly switched and began to deny all my claims for the same illness they had previously approved. I was shocked and bewildered, I could not believe how Aetna could be doing such a thing. What was happening, how could they just say NO! This wasn’t fair, I paid into this for 29 years… and was lost as to what to do.

I did some research on line, and found out this was a common thing all insurers were doing to people who had these kind of policies. What a rip off I thought. Here I thought I had a safety net. I was so angry and realised I was disillusioned about this system and having a safety net. I sat and cried fluctuating between anger, sadness, worry, the gamut of feelings. What should I do I thought, I need help and help fast. I couldn’t live without income. I did some more research and found Dell & Schaefer, I went through their website reading all the information and decided I need to call them to see if they could help me. My illness was not listed as a common illness for disability approval.

When I called them, they put me through immediately to someone and took some information. Later that day an attorney called me back and went through my situation explaining to me all my options and that they could help me. I wasn’t ready to make a decision on the spot, so I told them I would call them back. I was skeptical because at this point I didn’t trust anyone for numerous reasons and felt like all the systems I had faith in were failing me. Is this going to be another rip off, I thought?

After thinking about it for a day or two and consulting friends and family, I nervously called back Dell & Schaefer and I told them my concerns, we talked some more they never pressured me. I reluctantly agreed, not because of something they said, it was my own issue with trust now clouding my decision. Reflecting back that was the best decision I ever made. My attorney in the firm was Alex Palamara, I dealt with him exclusively and he always called me back, emailed me and let me know what was happening promptly. Nothing was ever too small for him to answer and he had compassion when I would complain about how unfair Aetna was being with their denial of my case. And YES, they did deny, and are still trying to find ways to deny me to this day 4 years later. Through the hard work and timely action taking by the attorney my appeal was reversed and my claim continues to be approved with the help of the attorney. I no longer have random calls from Aetna asking me repetitive questions that I already answered numerous times and the firm continues to coordinate the yearly reviews with Aetna and my physicians. I faced another denial at the two year mark when the policy changes the definition of gainful employment. Yea isn’t that beauty they sneak into the policy that you have really don’t understand. Alex anticipated that fought that and I have had a seamless benefit check now for 4 straight years.

I will not give up my representation, as educated as I am, in no way am I versed in disability law and the new ways insurance companies try to get out of paying the policy we have paid our hard earned money into for a safety net. I know things will not be easy and I will have to fight to continue my benefits, having Dell & Schaefer gives me security that someone will be there fighting for me and my benefits. I can’t thank them enough, I find them to be prompt, compassionate, knowledgeable and very fair with their fees. If you are thinking about hiring an attorney for representation you will be pleased with this firm. As a side note, my last years of employment I worked for a large hospital system, my job was coordinating with the hospital, physicians and Insurance companies to make sure the hospital would get paid. Specifically, I worked on denials of patients inpatient hospital bills. The insurance company would deny claims for the most unbelievable reasons. They know some people will just give up and not fight, that’s what they are counting on. I didn’t think they would do the same thing with STD and LTD policies, I was wrong and naive. Do yourself a favour, HIRE an attorney immediately from the beginning, otherwise the carrier will jerk you around till you give up, and you may inadvertently say or fill out a form wrong or miss a date and boom you are denied. You will never get your benefit you paid into. Hire Dell & Schaefer.

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