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A Story About Tragedy, Justice, and How to Beat Insurance Companies at Their Own Unfair Intoxication Exclusion Benefit Denial Game

My client, a young wife, survived this horrendous accident. Unfortunately her husband, who was driving, did not.

Can you imagine CIGNA insurance company withholding critical evidence from a grieving widow to help it unfairly argue that an intoxication exclusion clause voided coverage under her husband’s accidental death and dismemberment insurance policy? That’s exactly what CIGNA did to avoid paying over $1,000,000 in accidental death and dismemberment insurance benefits it owed to the young widow after her husband paid years of premium to protect her financially if something like this ever happened.

But a federal appeals court slammed CIGNA for doing it, and ordered CIGNA to pay it all.

 

SHATTERED NEWLYWED BLISS

Life as my client knew it changed forever after what began as a pleasant afternoon drive with her husband. Beautiful weather. They were newlyweds. He had a great job and often worked overseas, and they were inseparable when he was back home.

She was reaching over to the backseat to play with the family dog who was along for the ride as they approached a gradual curve in the road. Her husband, who was driving, briefly turned to look. Just as they both looked back up, they saw the eighteen-wheeler coming head-on toward them. In his brief moment of distraction, her husband had continued driving a straight path when the road curved, sending them into the oncoming truck’s path.

Suffering multiple bad injuries herself, it was a miracle my client survived the fiery crash at all. What was left of the car was hardly even recognizable. Tragically, her husband died in the hospital from massive injuries a few days later. It was an indescribable gut-punch. She was slowly recovering physically, but lost, scared and incredibly alone.

While no great consolation, at least her late husband, the sole breadwinner, had paid for a very expensive accidental death and dismemberment insurance policy with CIGNA to protect her from exactly such an event as this. At least, she thought, she would be OK financially in her grief.

 

CITING ERISA, AND A POLICY EXCLUSION FOR INTOXICATION, CIGNA DENIES THE WIDOW’S CLAIM FOR INSURANCE BENEFITS

Imagine the bewildered widow’s shock when she opened CIGNA’s denial letter explaining that her claim was governed by the little known federal law known as ERISA, and that it refused to pay her insurance benefits, claiming her husband was intoxicated. CIGNA claimed that her husband’s blood and urine samples proved he was intoxicated at the time of the crash, and that the accident report stated he was “impaired.” The insurance policy excluded coverage for accidents caused by an insured’s intoxication. A second gut-punch. She was still recovering mentally and physically, she was broke, and felt like she was swirling the drain. But no way in the world was he impaired. There was no doubt in her mind.

 

ILLEGALLY WITHHOLDING EVIDENCE: WHAT CIGNA KNEW BUT DIDN’T TELL THE WIDOW

What’s shocking is what CIGNA’s denial letter DIDN’T tell the widow when it denied her claim.

GIGNA’s denial letter didn’t tell her that it had hired an expert toxicologist to review her husband’s blood and urine samples. The expert gave GIGNA a written report that the samples COULD NOT support a determination of intoxication. In other words, CIGNA’S own expert directly contradicted what it told my client to support its denial of her claim.

CIGNA’s denial letter also didn’t tell her that the original accident report didn’t even say “impaired”. Rather, the original report was amended more than six months after the accident to say “impaired” only after a telephone calls from CIGNA to state police prompted the amendment. This was long after her husband had died, and just seven days after CIGNA received its toxicologist’s report that a finding of impairment COULD NOT be supported.

So now CIGNA had something it could say in its denial letter to support its decision – the police report now said “impaired”. CIGNA issued its claim denial letter soon afterward. The letter talked all about the police report saying “impaired”. Of course it made no mention of its own toxicology expert’s opinion that impairment could not be determined.

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