Accidental Death Benefits Recovered for Parents After Drug Exclusion Denial

Accidental Death Insurance Benefits Paid by Cigna After Denial for Alcohol and Drug-Related Drowning

Our clients were the beneficiaries of an accidental death insurance policy underwritten by CIGNA, insuring the life of their beloved 40-year-old daughter. She was their pride and joy, a wonderful soul and gift to the many she touched while here, and had an exceptionally successful career. 

She was in the gaming area at a casino resort getaway with her fiancé and some friends when she announced she was tired and going up to her room. When her fiancé returned to their room later, he was shocked to find water flowing out from under the door into the hall, and his fiancé drowned in the bathtub. 

The Policy Exclusion for Deaths “Caused by Voluntary Ingestion of Any Narcotic or Drug, Unless Prescribed and Taken as Prescribed.” 

The policy was governed by ERISA, as it was issued as part of her employment benefits plan. CIGNA refused to pay benefits, citing policy exclusions for deaths “caused by voluntary ingestion of any narcotic or drug, unless prescribed and taken as prescribed,” a common reason for the denial of accidental death and dismemberment insurance claims.

Her post-mortem blood tested positive for alcohol,  Ambien (a powerful sleep medication prescribed for insomnia),  Lexapro (an anxiety and depression medication), and Phentermine (prescription amphetamine). The Ambien and Lexapro were prescribed by her physician, and were found by CIGNA’s own toxicology expert to be only at “therapeutic”, or as prescribed, dosage levels when she drowned. According to the same toxicologist, the prescription amphetamine, while not prescribed by her physician, would only have countered any drowsiness effects of the combined alcohol and prescribed drugs.

CIGNA argued that a prescription package insert that normally accompanies an Ambien prescription advises not to take with alcohol, and thus the medications were not “taken as prescribed”. However, CIGNA’s toxicologist admitted that, while package inserts are usually given to patients, he had no idea if it was in our case, and the administrative record (under ERISA regulations, the administrative record built during the administrative appeal process forms the only admissible evidence for the later trial in federal court) contained no evidence that she actually got the insert, or that her physician or any other source recommended or communicated to her that she should abstain from alcohol. 

We argued that the exclusion, at best, was ambiguous as to what “as prescribed” means – Dosage only? What the prescribing physician actually communicates to the patient? Everything written on a manufacturer’s insert, especially with no evidence of it being communicated to the patient? 

Faced with the burden of proof on its exclusion, and that exclusion ambiguities are to be construed in favor of coverage, CIGNA finally paid a confidential sum in settlement. But it should have done at the outset before going the route of bogus and meritless legal gamesmanship to withhold the wee monetary consolation a daughter meant to bestow upon her parents in the event of her demise.

Victims Of Unfair Insurance Denials Should Always Appeal Unfair Claim Denials

In the end, because our client continued to fight, appealing the insurance company’s denial rather than just accepting it as the final word, was able to secure the deserved benefits. 

Unfortunately, insurance companies unfairly deny legitimate claims every day. But anyone faced with an unfair claim denial should continue to fight and appeal the denial. These unfair denials can be overturned with stronger evidence, properly presented. 

It was an honor to help our client overturn such an unfair claim denial.