Court Affirms Denial of AD&D Benefits due to Participant Drug Use

January 10, 2008 ( - The U.S. District Court for the Eastern District of Michigan has affirmed an accidental death and dismemberment (AD&D) plan administrator's decision to deny benefits to the spouse of a woman killed in a car accident who was found to have illegal drugs in her system.

In its opinion, the court pointed out Linda Heiple’s insurance policy contains a provision that excludes losses to which voluntary drug use, without a prescription, is “a contributing cause.” The toxicology report for her showed she tested positive for metabolites of cannabis and cocaine.

The court determined that in light of the evidence presented to the plan administrator, it did have a rational basis for denying benefits based on the provision excluding losses contributed to by voluntary drug use. A police report indicated Heiple was at fault for the accident and Insurance company Jefferson Pilot’s reviewing physician concluded that the presence of cannabis and cocaine in her system could have been contributory to the collision.

Linda’s spouse, James Heiple questioned whether Jefferson Pilot sufficiently established a causal connection between the metabolites in his wife’s bloodstream and her death. According to the court, while James Heiple’s reasoning might provide a basis for disagreeing with the plan administrator’s decision, none showed that Jefferson Pilot lacked evidentiary basis or reasonable rationale for its decision.

James Heiple presented evidence to the court showing seven co-workers believed she left an event uncompromised by any drug use. He maintained that the reviewing physician was conclusory in his analysis, unqualified in relevant areas, failed to account for the effect of pain relievers and possible false positive toxicology results, and was not provided information later available.

The court said James Heiple also alluded to the possibility of a conflict of interest, in that Jefferson Pilot both pays for claims and makes decisions about whether to pay them. However, the court determined Heiple provided no factual basis for suggesting that the insurance company acted improperly.

The case is Heiple v. Jefferson Pilot Financial Insurance Co., E.D. Mich., No. 07-12319-BC, 1/8/08.