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Compliance August 10, 2004
Wife Is Not Entitled to Benefits After Spouse's Drunken Lawnmower Accident
August 10, 2004 (PLANSPONSOR.com) - An insurance
plan provider did not violate the Employee Retirement Income
Security Act (ERISA) in denying a plan beneficiary's claim
for benefits after her husband was severely injured in a lawn
mower accident while intoxicated.
Reported by Eric Hazard
The US District Court for the District of Maryland, in awarding summary judgment to the defendant, found Provident Life & Accident Insurance Company, the provider of the accident injury benefit plan, was correct in determining the injury was not covered under “accidental bodily injury” provisions of the plan. The court found ample evidence to support the denial of benefits under plan language that denies “accident” coverage if the participant is intoxicated.
Edna Lamm’s husband was an employee of Northrup Grumman Corp. and was insured under an accidental injury benefit plan when he had his right hand severed in a lawn mower accident. Following the accident, Edna submitted a claim for benefits that was denied by Provident after the insurance provider determined her husband was inebriated at the time of the accident.
Edna filed suit against Provident, charging the firm of violating ERISA in denying her claim for benefits. In her suit, Lamm argued that her husband was not legally intoxicated at the time of the accident because the toxicology report taken by the hospital after her husband was injured reflected that his blood alcohol level was 0.076%, which is below the legal limit in Maryland.
The district court disagreed with this contention. Relying on statistics from the US Department of Health and Human Services, the court found that Lamm’s husband’s blood alcohol level would have decreased 0.015% per hour. At the time her husband’s blood alcohol level was taken, it was two hours after the accident, meaning that his blood alcohol would have been at least 0.106% at the time of his accident, the court determined.
>Even though the court finds the situation “extremely unfortunate,” District Judge J. Frederick Motz said it does not change the facts that Provident’s plan had a provision conferring “discretionary authority [upon the plan administrator] to interpret the Plan and the Policy and to determine eligibility for benefits.” Thus, “The decision to deny benefits to the plaintiff was entirely reasonable and supported by substantial evidence,” Motz said.
The case is Lamm v. Provident Life & Accident Insurance Co. , District of Maryland, No . JFM-04-1341.