Archive for the ‘Exclusion’ Category

By TIM HULL

(CN) – An insurance company must award benefits to an Ohio man who lost his leg in a drunken motorcycle crash, the 6th Circuit ruled, because the incident falls within the broad definition of an “accident.” Read more

Reporting to Medicare

The purpose of these reporting requirements is to enable the Centers for Medicare & Medicaid Services (CMS) to determine whether those covered by Medicare are also covered by other insurance that, by law, must pay primary to Medicare. Read more

by David S. Hilzenrath of The Washington Post, www.washingtonpost.com

A proposal to make preexisting health conditions irrelevant in the sale of insurance policies could help not just the seriously ill, but also people who might consider themselves healthy, documents released Friday by a California-based advocacy group illustrate. Read more

by Roy Harmon, III, www.healthplanlaw.com

A typical plan will contain an exclusion for accidents or injuries resulting from intoxication, unlawful conduct and so forth. How the plan states the exclusion can vary quite a bit, and the distinctions can make a significant difference in outcomes.

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In MacLeod v. Proctor & Gamble Disability Benefit Plan, 460 F. Supp. 2d 340 (D. Conn. 2006) the administrator denied the participant’s application for benefits on the grounds that the claimed disability resulted from the participant’s prior military service and therefore was excluded from coverage. At oral argument, the administrator admitted that its decision was based on the “categorical military exclusion” and did not entail an individualized consideration of the particular facts of the application. The plan at issue, however, specifically provided that in the event of an “illness, accident or injury occurs while the Participant is working for pay for some person or organization other than the Company, payment of benefits under the Plan shall be made only at the discretion of the [administrator] after their review of the facts of the case.” Although the court did not find that the administrator’s conclusion that the participant’s disability occurred during his time in the military was arbitrary and capricious, it concluded that the manner in which the administrator evaluated the claim was an unreasonable interpretation of the plan language and remanded the matter.

In Thomas v. Reliance Standard Life Insurance Co., 487. F. Supp. 2d 697 (D.S.C. 2007), the court examined whether death by asphyxia from vomitus resulting from drug self-administration was an accident within the terms of an ERISA-governed policy. Reliance Standard denied benefits pursuant to the policy’s exception for losses caused by suicide or intentionally self-inflicted injuries because the insured had expressed a desire to commit suicide in the exact place he was later found dead. Reliance Standard further argued that the insured’s intentional use of prescription drugs contributed to his inability to maintain a clear airway. The court sided with the insurer, citing evidence that the insured “intended to commit suicide, ingested dangerous narcotic medication, and died as a result.” Accordingly, the court concluded that the insurer “reasonably found that [the insured] intended the ultimate result, although he may not have anticipated the exact means.”

In Bond v. Ecolab, Inc., 2007 WL 551595 (E.D. Mich. Feb. 21, 2007, an ERISA plan participant died while engaging in autoerotic asphyxiation. The police and medical examiners concluded that the participant’s death was accidental. The plan’s claims administrator, MetLife, denied the beneficiary’s claim for benefits based on the plan’s exclusion for self-inflicted injuries. In entering judgment in favor of defendants, the district court rejected plaintiff’s argument that the death certificate’s identification of the manner of death as accidental was controlling and held that MetLife’s decision to deny benefits was not arbitrary and capricious because MetLife’s determination that the participant’s intentional disruption of oxygen to his brain was a self-inflicted injury and was not unreasonable in light of the plan’s language.

In Eckelberry v. Reliastar Life Insurance Co., 469 F.3d 340, the Fourth Circuit affirmed the insurer’s determination that the decedent’s fatal automobile collision did not qualify as an “accident” as defined under the subject ERISA plan. The insured died after he lost control of his car and collided headlong into the rear of a tractor trailer parked on the side of the road. At the time of the collision, the insured was not wearing his seat belt, and his blood alcohol level was 50 percent higher than the state’s legal limit. For purposes of establishing coverage, the plan defined accident as an “unexpected and sudden event in which the insured does not foresee.” The court determined that absent evidence of an insured’s subjective intent, an “objective analysis” governs whether death was “unexpected” when that term is undefined in accidental death policy. The court found that the circumstances of the insured’s accident were “perfectly consistent with his inebriated state” and noted that “all drivers know, or should know, the dire consequences of drunk driving.” In reaching its decision in favor of the insurer, the court joined what it characterized as “near universal accord that alcohol-related injuries and deaths are not ‘accidental’ under insurance contracts governed by ERISA.”

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In Arnold v. Hartford Life Insurance Co.( 542 F. Supp. 2d 471 (W.D. Va. 2008), Hartford denied a beneficiary’s claim for accidental death benefits, concluding that the insured’s death was not due to an “injury” as defined in the policy. The insured died at the scene of a motorcycle crash. The immediate cause of death was a closed-head injury with cervical spine fracture. At the time of the crash, the insured was legally intoxicated. Read more