Insurance policy intoxication exclusions are as ambiguous as they come

In a recent ruling by the Eighth Circuit the surviving husband of a mother of two was awarded accidental death benefits following his wife’s death. The deceased wife was covered by an ERISA governed accidental death policy insured by Unicare Life and Health Insurance Company. The autopsy reported listed the cause of death was “mixed drug intoxication.” The deceased had apparently ingested several different prescription medications and died as a result.

After denying the husband’s claim for benefits Unicare Life’s decision was reversed by a district court presiding over the ensuing lawsuit. In denying the husband’s claim Unicare alleged that the death was not accidental and therefore not covered by the policy and that if it was then it was excluded by the policy’s intoxication exclusion.

The Plan Did Not Contain the Necessary Discretionary Language to confer UniCare discretionary authority.

In reaching its decision, the district court focused on the language in the claims provisions to determine if the plan had conferred discretionary authority on UniCare. Finding that such discretionary language did not exist the court reviewed UniCare’s decision de novo, thereby giving the plaintiff husband a fair chance. Under the court’s de novo review, the parties were able to introduce evidence outside the administrative record to support their positions.

UniCare pressed forward various arguments to support its decision to deny the plaintiff’s claim. All of its arguments failed.

Death by “mixed drug intoxication” was an accident

As the court explained “an event is an accident if the decedent did not subjectively expect to suffer ‘an injury similar in type or kind to that suffered…” UniCare’s position was that the death was a suicide and therefore not an accident. The court disagreed.

UniCare pushed forward its secondary argument that the death resulted by intoxication and therefore excluded under the policy. The court, however, disagreed.

The Plan’s Intoxication Exclusion is Limited Only to Deaths Contributed to by Alcohol Intoxication

The plan’s exclusion stated that no benefit will be paid for a death that results from being intoxicated. “Intoxicated” was defined by the plan as “legally intoxicated as determined by the laws of the jurisdiction where the accident occurred.”

Because it was an exception to coverage, UniCare had the burden of proving that the exclusion applied. Based on the specific language of the intoxication exclusion the court found that the exclusion was limited only to deaths contributed to by alcohol intoxication and found in favor of the husband.

This case presented several interesting issues that were ultimately decided in the plaintiff’s favor. Of particular interest was the intoxication exclusion which defined “intoxication” according to the laws of the jurisdiction where the accident occurred. The applicable law defined intoxication with reference only to the public offenses of drunk driving and public intoxication. Since the wife’s death involved neither the exclusion did not apply. The court explained that a reasonable plan participant would have understood that the plan’s intoxication exclusion is intended to apply to death caused by committing acts, such as driving, while intoxicated; not to situations where the immediate cause of death is ingestion of a lethal mixture of drugs have been prescribed for use by the decedent.

Other jurisdictions have decided cases dealing with similar policy exclusions. Some policies, like the one in this case exclude coverage when the loss “resulted” from the intoxication. Others state that the exclusion applies where the loss occurred “while” intoxicated. If that doesn’t seem ambiguous enough these policies refer to the “jurisdiction where the accident occurred” for clarification on what “intoxication” means. Since most laws dealing with intoxication refer only to driving while intoxicated or public intoxication it leaves much open for interpretation when accidents do not occur in either of these contexts. It is interesting to see courts apply these exclusions as the rulings are almost as unsure as the policy language.

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

Leave a comment or ask us a question

There are 3 comments

  • Jake, as most life insurance policies will not pay in the event of suicide, then the fact the death was not ruled such is definitely beneficial. Another concern that may exist is the fact that life insurance policies will also typically not pay if death occurred during the act of committing a felony. As fentanyl is a controlled substance, if it was not legally prescribed the insurance carrier may try make some argument that death occurred during the commission of a felony. It is a stretch, but something to consider/be aware of. Has a claim been filed under the life insurance policy? If so, what is the status? Please feel free to contact our office if you would like to discuss further.

    Stephen JessupJun 2, 2020  #3

  • If the cause of death on the death certificate is listed as an accident and the cause was acute fentanyle intoxication. Does this meet the standard of an accident and not an accident while intoxicated? I know that’s splitting hairs. It was not ruled a suicide.

    JakeJun 2, 2020  #2

  • Do NY State Courts entertain “degree of causation” with regard to alcohol exclusions in Accidental Death and Dismemberment policies?

    Michael A.Feb 21, 2020  #1

FAQ

Do you work in my state?

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.

Do I have to come to your office to work with your law firm?

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.

How can I contact you?

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   *****

Sherri L.

I am very satisfied with my experience working with Dell & Schaefer. From the first intake call to the assignment of an attorney, I always felt that my questions and concerns were answered completely and timely. The attorney that handled my appeal made a very overwhelming, difficult process manageable and assisted us step by step. When dealing with illness and disability, you are not able to stand up and fight for yourself and this is where the vast experience and recommendations with LTD were relied upon. In addition, the legal assistant assigned to my case was a valuable asset to the outcome by always keeping me updated on the progress of the case and any necessary documentation that was required from me. Communication from this team was excellent.

Read 424 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us