Fist Fight Falls Under Health Plan's Violent Behavior Exclusion

January 11, 2006 ( - The US District Court for the Western District of Missouri found that it was not unreasonable for a health plan administrative committee to determine that a fist fight fell under the violent behavior exclusion of a health care plan.

In Jennings v. Administrative Committee of Wal-Mart Stores Inc. Associates Health and Welfare Plan the court granted summary judgment to the committee, saying it did not act arbitrarily in denying benefits to a participant whose injuries were caused by a fight.

According to the court opinion, a Wal-Mart employee went to a doctor claiming he injured his right hand three days before in a car accident, but later went to another doctor and said he had hurt his hand when he punched someone in a fight.

On two occasions when the plan administrative committee requested further information about his injury, the employee claimed that, when a fight had started between two people and he tried to separate them, he had to defend himself against one of them, the court said.

The health plan’s administrative committee denied coverage for surgery and other treatment of the hand injury, citing an exclusion in the plan for injuries caused by violent behavior.   On appeal, the employee’s medical claim was again denied.   The employee then filed a lawsuit.

In its decision the court said the committee’s interpretation of the plan’s language was reasonable and also that the employee’s claim that he had reacted in self defense did not prevent the violent behavior exclusion from applying.