Many participants in ERISA insurance plans mistakenly assume that they are automatically entitled to their disability benefits if and when they need them. They may be unaware that their insurance policy, which is also a contract, may exclude coverage in certain situations.
For instance, if you were drinking alcohol or had recently consumed alcohol before an accident or injury for which you are seeking disability benefits, you may be facing an uphill battle. Even if you were under the legal limit for your blood alcohol content (BAC), your ERISA disability insurance company could use this fact to deny you benefits.
Rejection on these grounds is legal in this state but may not be appropriate in all circumstances or permissible in all contracts. A skilled ERISA attorney may be able to help you if your insurance company is denying you coverage based on the intoxication exclusion for ERISA disability insurance in Texas.
The intoxication exclusion for disability insurance in Texas states that they exclude from coverage disabilities that stem from any accident for which the intoxicating influence of alcohol, drugs, or any impairing substance was a factor.
While the insured party may not be able to argue that such an exclusion is not present in the policy, the way the insurance company obtained their information, what information they are using to make their denial decision, and how the policy is interpreted could be contested and used in favor of the claimant receiving their benefits.
An insurance company that denies disability coverage based on their policy’s intoxication exclusion must conclude that the insured was intoxicated at the time of the accident based on scientific proof. Furthermore, they must prove that the intoxication was the cause of their accident or injury.
In White v. Life Insurance Company of North America, the U.S. Fifth Circuit Court of Appeals ruled that the presence of intoxicating substances is not sufficient evidence by itself to justify a denial of coverage based on intoxication. Additional evidence, such as witness statements about the state of the claimant at the time of the injury, documented physical symptoms, and conclusive evidence of a specific amount of such substances would be required to enforce the denial. In other words, information used to support an intoxication exclusion for a Texas ERISA disability insurance policy must be tangible and have factual support.
When an insurance company pays on a claim, they are almost always losing money. Therefore, ERISA insurance companies often look for reasons to deny disability claims. If they believe alcohol was at all involved in the circumstances that led to you filing for disability coverage, they can and likely will use this information to contest your claim.
Fighting a coverage denial based on an intoxication exclusion for ERISA disability insurance in Texas can become a complex legal situation. The stakes are high for your physical wellbeing and financial future during this time, so seeking an experienced Texas ERISA attorney may better position your case for a positive outcome.
Qualified lawyers may be able to find multiple legal reasons why your ERISA insurance company must provide disability benefits to you. Call today to find out more about ERISA representation and how a dedicated attorney may be able to assist you.
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