Richmond v. Life Ins. Co. of N. Am., 2022 WL 10225155 (8th Cir. 2022)
A participant in an employer-sponsored benefit plan died after injecting herself with a “cocktail of unprescribed narcotics,” and her surviving spouse’s claim for accidental death benefits was denied under the plan’s exclusion for the “voluntary ingestion of any narcotic…unless prescribed.” Following an unsuccessful internal appeal, the spouse sued. The trial court upheld the denial, and the Eighth Circuit has affirmed the trial court’s ruling.
Reviewing the denial under the deferential “abuse of discretion” standard, the court analyzed first whether the insurer’s interpretation of plan language was reasonable, and second whether its application of that interpretation to the facts was supported by substantial evidence. According to the court, the insurer’s interpretation was reasonable because, among other things, it was not inconsistent with the plan’s language, did not render any plan language meaningless, and did not conflict with ERISA’s substantive or procedural requirements. The court was not persuaded by the spouse’s argument that it was unreasonable to interpret “ingestion” as encompassing self-injection. Because it was undisputed that the participant died from willingly injecting herself with the combination of narcotics, there was sufficient evidence to support the insurer’s application of the voluntary ingestion exclusion to the participant’s death. In addition, the court rejected the spouse’s argument that the claim was not afforded full and fair review as required by ERISA’s claims procedure regulations, pointing to the plan’s two-stage appeals process and the “well-reasoned, eight-page, single-spaced final denial letter citing nearly all the evidence.”
EBIA Comment: On its face, the application of the voluntary ingestion exclusion to this set of facts may seem clear cut, but the court’s analysis of whether the insurer’s interpretation was reasonable tilted only slightly in the insurer’s favor. The insurer’s thorough process and detailed denial letter perhaps helped to keep its decision from being overturned. For more information, see EBIA’s Self-Insured Health Plans manual at Section XIII.E (“Coverage Limitations and Exclusions”). See also EBIA’s ERISA Compliance manual at Sections XXXVI.C (“Standard of Judicial Review Applied to Benefit Decisions Under ERISA Plans”) and XXXIV.N (“How to Protect Claim Denials From Being Reversed in Court”).
Contributing Editors: EBIA Staff.