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Whether an insurance company, employer, union or other ERISA governed
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What Is Intoxication Within the Scope of an Insurance Exclusion?

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In an all too familiar and tragic event, the US District Court for the District of New Jersey in Lake v. Aetna Life Ins. Co., — F.Supp.3d —-, 2014 WL 5339325 (D.N.J., October 21, 2014) ruled in favor of AETNA holding, “a reasonable fact finder could not find [AETNA] abused its discretion in denying benefits” to the insured’s beneficiary. Rather the uncontested facts disclosed that the insured driver had, “crossed over the center line on an empty, properly painted road, ran off the road into a ditch, and crashed into a tree.” His blood alcohol content drawn hours after his death was 0.133%w/v which is greater than New Jersey’s legal limit of 0.08% w/v. See NJ Stat. Ann. 39:4-50. Accidental Death Claim

The key AETNA policy language in this Accidental Death and Dismemberment (“AD&D”) insured plan carved out a broad exclusion providing that AETNA would not pay benefits for a loss “caused or contributed to by … [a] covered person’s being intoxicated or being under the influence of narcotics unless administered or consumed on the advice of a physician.” Although the word “intoxicated” is most often association with excess alcohol, other types of intoxication arise, such, drug intoxication, food poisoning (clostridium botulinum or drinking too much water. The New England Journal of Medicine, often considered the leading medical journal in the world, reported in a 2005 article that close one sixth of marathon runners in the Boston Marathon developed some degree of water intoxication (hyponatremia) which is dilution of the blood caused by drinking too much water. See N Engl J Med 2005; 352:1516-1518

Would the Court have ruled differently if the driver had been intoxicated by too much water, or a bad meal causing botulism? The point of the question is that AD&D policies are vague. Given that when the insurer has discretion arising under ERISA to interpret the ambiguity in its favor, sloppy drafting inures to the insurance company’s favor and against the victims, the insured’s beneficiaries.


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