Aetna Disability Denial Upheld - Dell Disability Lawyers

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:

  • The death certificate. Cause of death was listed as due to “multiple blunt force injuries.”
  • The Official Oklahoma Traffic Collision Report. There were “no skid marks or yaw marks on the road to indicate evasive movement from [the] vehicle.”
  • The toxicology report. This showed the decedent’s toxicology was positive for methamphetamine and amphetamine.
  • The autopsy report. This included information that in the car at the time of the crash, there was “a pipe containing a green leafy substance.”
  • The lab analysis. Decedent’s toxicology report was positive for 0.35 mcg/ml of amphetamine and 2.2 mcg/ml for methamphetamine.
  • Decedent’s prescriptions history. Decedent was taking the prescription drug, Adderall, which is an amphetamine. 

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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Aetna Reviews
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Aetna

Aetna STD has been a nightmare since the beginning

Reviewed by Michael S. on May 13th 2020   Verified Policyholder
I had surgery on 2/27/2020. Aetna STD has been a nightmare since the beginning. Total mismanagement of everything. I have never been paid consistently & have had to manage... read more >
Reply
Sent on May 13th 2020 by Attorney Jay Symonds

Michael: Generally speaking Hartford now manages the Aetna claims. The timing of STD claims is difficult because the benefit is a week to week benefit but the medical i... read more >

Aetna

Aetna leaves me at risk of losing my job and without compension

Reviewed by Amber P. on March 6th 2020   Verified Policyholder
I applied for STD 2/24/2020 for eye surgery. Documents were submitted. Aetna noted they contacted the doctor and needed the APS form; already was submitted. So, the dr sub... read more >
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Aetna puts their clients through hell with their games

Reviewed by Joe Doe on April 19th 2019   Verified Policyholder
I have been on Aetna disability for a couple of years now and have surround sound to be extremely cunning and ruthless. They put put claimants through hell for the first 6... read more >
Reply
Sent on April 19th 2019 by Attorney Jay Symonds

Joe, you make an excellent point. If a claimant has questions or concerns regarding the treatment they are receiving during the claims process it is wise to contact cou... read more >

Aetna

It's been over 3 months, and I've only received one payment from Aetna

Reviewed by Crystal A. on January 24th 2018   Verified Policyholder
I have been struggling with Aetna to get my short term disability, its been since 10/16/2017 and I have only received one payment since. My doctors send in my forms and th... read more >
Reply
Sent on January 24th 2018 by Attorney Stephen Jessup

Crystal, Aetna should have rendered a final decision on your claim well over a month ago. Please feel free to contact our office to discuss your situation to best deter... read more >

Aetna

Aetna people are thieves, crooks and liars.

Reviewed by Anonymous on August 23rd 2017   Verified Policyholder
It is my opinion that Aetna people are thieves, crooks and liars. I purchased a disability policy from my employer with Aetna. I became disabled because of a heart conditi... read more >
Aetna

Aetna is definitely committing a crime and they need to be stopped.

Reviewed by on April 8th 2017   Verified Policyholder
Aetna denied my claim after providing all my doctor notes 5 times, all my ER records. stating that i did not see my doctor until 3/3/17 but my out of work date was 2/16/17... read more >
Reply
Sent on April 8th 2017 by Attorney Stephen Jessup

Sarah, as your claim has been denied your next step is to file your administrative appeal. As Aetna typically only allows for one level of appeal before a lawsuit must ... read more >

Aetna

I hate Aetna

Reviewed by Pamela L. on April 7th 2017   Verified Policyholder
My story is the same as most here. I suffer from several afflictions. T1 diabetic for 42 years, stage 3 kidney disease, neuropathy pain in feet legs and hands, carpal tunn... read more >
Reply
Sent on April 7th 2017 by Attorney Stephen Jessup

Pamela, what is the current status of your claim with Aetna? Please feel free to contact our office to discuss what options/rights you may still have against Aetna.

... read more >
Aetna

Aetna denied me and then I got fired from my job

Reviewed by Jeremy on April 3rd 2017   Verified Policyholder
I got denied and got fired right after my Dr submitted my paperwork for leave, due to being in the hospital. They fired me for being in the hospital. and now paying unempl... read more >
Reply
Sent on April 3rd 2017 by Attorney Stephen Jessup

Jeremy, when was your claim denied? Did you file an appeal? Please feel free to contact our office to discuss the denial of benefits to determine what rights you may ha... read more >

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