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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