In LePino v. Anthem Blue Cross Life & Health Ins. Co., No. 22-CV-4400 (NSR), 2023 WL 5001439 (S.D.N.Y. Aug. 4, 2023), New York Southern District Judge Nelson S. Román granted Anthem’s motion to dismiss Plaintiff’s action seeking to recover proceeds under an ERISA-governed life insurance policy.
Plaintiff was the sole beneficiary to a life insurance policy issued to decedent’s employer, and under which he was a participant. The insured died on August 29, 2021, due to “Acute Intoxication Due to the Combined Effects of Heroin, Fentanyl, P-Fluorofentanyl and Xylazine.” Anthem denied Plaintiff’s claim for the life insurance proceeds citing an exclusionary provision that “No benefit will be paid by this coverage for a death or loss that results from, or that is caused directly, wholly or partly by: … Being under the influence of any drug or substance.” Plaintiff initiated the instant action.
Both parties characterized the Insured’s death as a drug overdose but offered differing interpretations of the exclusionary provision. The Court noted that plain language of the provision excluded coverage for deaths “caused directly, wholly or partly by … [b]eing under the influence of any drug or substance.” It noted that the phrase “under the influence of” is defined by Merriam-Webster Dictionary as simply “being affected by.” Thus, the Court concluded that a natural reading of the exclusion meant that it applied to any death caused by an incident in which the insured was affected by drugs.
Plaintiff offered two arguments for a different interpretation. First, she argued that the exclusion should be read to apply only to deaths resulting from accidents such as motor vehicle or ski accidents that occur while a person is under the influence of drugs or a substance. Second, Plaintiff argued that because the word “overdose” was not explicitly written into the exclusion, the insured’s cause of death was not unambiguously barred under the terms of the Policy. She asserted that because there could be more than one reasonable interpretation of a policy term, the Court must adopt the interpretation most favorable to the insured party.
The Court disagreed. First, it found that the plain meaning of the exclusion did not support Plaintiff’s reading. The Court noted that because the exclusion covers deaths that are “partly” caused by being under the influence of drugs, that term indicates the exclusionary language is broader than Plaintiff’s interpretation. Second, the Court found that the insured’s death was not excluded simply because the term “overdose” was not explicitly stated in the exclusion. It again pointed to the broad language of the provision finding that it encompassed death from drug overdose. Finally, the Court distinguished Plaintiff’s citation to the case of Miller v. Continental Ins. Co., 40 N.Y.2d 675 (1976), finding that Miller examined whether the insured’s death due to drug overdose was intentional or self-inflected as opposed to an accident. It did not examine any drug-related exclusion.
The Court concluded it was clear by the plain and unambiguous language of the Policy that the circumstance of the insured’s death did indeed fall within the exclusionary provision, and therefore Plaintiff could not prevail on her claim.
As this case demonstrates, entitlement to ERISA life insurance proceeds can be a difficult arena to navigate, both during the claims process, and potentially in litigation. If your claim for life insurance proceeds has been denied, contact us for assistance.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
LEAVE YOUR MESSAGE
We know how to get your insurance claim paid. Call today at: