Health Insurance And Intoxication Exclusions

Insurance attorneys in Dallas County need to be able to know how the courts interpret exclusions in policies when the exclusions rule out coverage for injury resulting from intoxication of narcotics. The United States Western District Court in Austin issued an opinion in June of 2015, dealing with this issue. It is styled, Eleanor Crose v. Humana Insurance.
This is an adverse ruling to Crose involving a summary judgment.
Crose is insured under a health insurance policy issued by Humana. Crose suffered a stroke which left him mentally and physically impaired. He filed a claim which Humana rejected citing a policy exclusion rendering benefits non-payable when the insured’s injury is “due to being intoxicated or under the influence of any narcotic unless administered on the advice of a health care practitioner.” Crose sued for violations of the Texas Insurance Code Sections under 541.060 and 542.051.
At about 9PM on June 23, Crose ingested MDMA, commonly known as “ectasy.” Crose and friends had a normal evening for themselves with Crose complaining of nausea and a severe head ache. Crose’s companion went to bed about 2AM and Crose stayed awake. At 9AM, Crose was found non-responsive and in a pool of vomit. It was determined he had suffered a stroke caused by bleeding within his brain.
Various doctors opined by pointing at the medical evidence in the case that the cause of the stroke was the MDMA.
Attorneys for Crose argued the term “narcotic” is not defined in the policy. They also pointed out that MDMA is not defined as a narcotic in the Texas Controlled Substances Act and that the federal DEA classifies MDMA as a non-narcotic.
This court was unpersuaded by this argument and found MDMA to be included in the policy as a narcotic.
The court then turned to whether or not Crose’s stroke was “due to … being under the influence of” MDMA.
Humana had to prove, to a reasonable degree of medical probability and scientifically reliable evidence, that Crose’s use of MDMA caused the stroke. After reviewing the evidence, the court concluded favorably for Humana.
These types of cases can be difficult to prove. But they can be proved. It is necessary to understand what the courts are looking to find in the evidence and the exact policy language, in order to make their rulings.