Denial of "Self-inflicted" Overdose Expenses Upheld

August 6, 2003 ( - A health plan sponsor's decision to refuse payment of medical expenses incurred as a result of a participant's drug overdose was not arbitrary and capricious.

>The US District Court for the Western District of Michigan found the participant’s expenses were properly denied under a provision in the health plan that excluded coverage for self-inflicted injuries.   Judge Gordon J Quist found the health plan “could reasonably conclude that [the beneficiary] intentionally ingested the drugs for a recreational, rather than a therapeutic, purpose and, that based upon his experience, he knew or should have known of the risks involved with taking controlled substances for an improper purpose,” according to Washington-based legal publisher BNA.

>Also, the court noted that many other federal courts have upheld the denial of benefits under self-inflicted injury exclusions for the intentional misuse of drugs.   “[T]he proper inquiry in determining whether the exclusion for intentionally self-inflicted injury applies is not whether the person intended death or the specific injury that resulted, but whether the person was aware that ingestion of drugs or engaging in other risky behavior could produce some injury,” the court said.


>Laurie Landis and her husband Michael were covered under a group health plan sponsored by Laurie’s employer, Syndicate Systems Inc. Syndicate operated as the plan’s administrator, while Healthcare Resources Group LLC acted as the plan’s claims administrator.

>In February 2001, Michael died as a result of a drug overdose.   Prior to his death, Michael underwent several years of drug abuse treatment.

>Before passing away, Michael was rushed to the emergency room, expenses which Syndicate later denied payment for.   Syndicate said the reason for the refusal of payments was the plan’s provision excluding coverage for self-inflicted injuries.

Laurie sued Syndicate and Healthcare Resources alleging they violated the Employee Retirement Income Security Act (ERISA) by denying payment for her husband’s medical costs. Healthcare Resources was dismissed as a defendant in an earlier decision.

The case is Landis v. Healthcare Resources Group LLC, W.D. Mich., No. 1:02-CV-530, 7/3/03.