Insurance policies are written to favor the insurer by including coverage exclusions, and the courts won't help beneficiaries litigate around them.
Last week, the Fifth Circuit Court of Appeals upheld a decision to deny a widow's claim on an accidental death insurance policy, finding that the insurer did not have to pay under the policy's alcohol exclusion
After a night of heavy drinking, Wesley Vincent was found face-down in front of his house by his wife, Cheryl Likens. He was taken to the hospital but eventually died.
Likens tried to collect as the beneficiary of an accidental death insurance policy. The policy covers losses, such as death or dismemberment, resulting from an "Injury," defined as bodily injury resulting directly from accident and independently of all other causes which occurs while the Covered Person is Covered on the Policy. Loss resulting from a) sickness or disease ... or b) medical or surgical treatment of a sickness or disease, is not considered as resulting from injury. The policy also excludes coverage for "any loss resulting from ... injury sustained as a result of being legally intoxicated from the use of alcohol."
Hartford Life and Accident Insurance Company denied the claim after determining that the injury resulted from being legally intoxicated from alcohol. Likens sued, and the district court granted summary judgment for Hartford based on the alcohol exclusion.
On appeal, Likens argued to the Fifth Circuit Court of Appeals that the district court erred in interpreting the contractual term "legally intoxicated" as unambiguously not requiring a person to be engaging in an illegal act. The Fifth Circuit found that the meaning of "legally intoxicated" was plain, but even if it were ambiguous, her proposed definition was unreasonable.
Here, the Fifth Circuit adopted the Fourth Circuit's interpretation that the plain meaning of "legal intoxication" is that one is intoxicated according to the definition specified in the law of that jurisdiction.
Thus, in this insurance contract, "legally intoxicated" meant: (A) not having the normal use of mental or physical faculties by reason of the introduction of alcohol, a controlled substance, a drug, a dangerous drug, a combination of two or more of those substances, or any other substance into the body; or (B) having an alcohol concentration of 0.08 or more. It could also be defined as not having normal use of physical and mental faculties.
Vincent had a blood alcohol content of 0.262 percent, over three times the legal limit. The Fifth Circuit noted that no matter what reasonable definition of legal intoxication is used, Vincent met it.
The Fifth Circuit Court of Appeals concluded that the alcohol exemption was applicable. The court noted, "On these facts, intoxication may not have been the only cause, but it does not have to be so to satisfy the exclusion."
- Cheryl Likens v. Hartford Life & Accident Insurance (Fifth Circuit Court of Appeals)
- Ambiguous Pre-Approval Terms Can Be Hazardous to Your Case (FindLaw's Fifth Circuit Blog)
- Negligent Misrepresentation Reversal Can Rock You Like a Hurricane (FindLaw's Fifth Circuit Blog)