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Health Care Services and Financing: Health Insurance: Losses Due to Intoxication ("UPPL")

Laws that prohibit exclusion of insurance claims arising from intoxication of the insured.



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Expander Policy Description

(Period Covered: 1/1/1998 through 1/1/2013)

This policy topic covers laws that prohibit exclusion of insurance claims arising from intoxication of the insured.  

In 1950, the National Association of Insurance Commissioners (NAIC) developed a model law entitled the Uniform Accident and Sickness Policy Provision Law (UPPL).  If enacted by States, it would permit insurers to include a provision in insurance policies that reads as follows:

The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician [1].

In most cases, jurisdictions with provisions reflecting this model law (also termed insurance exclusion) use this identical wording.

In contrast, in some jurisdictions, statutes and/or regulations explicitly prohibit insurers from denying payment for insurance benefits for losses due to the intoxication of the insured.  For example, South Dakota's statute prohibits insurers from denying health/sickness insurance benefits for injuries sustained while under the influence of alcohol or drugs. 

Most State statutes and regulations that either permit or prohibit this form of exclusion apply to health (sometimes called sickness) insurance. Laws in some jurisdictions also apply to accident, long-term care, disability, and/or life insurance. 

Almost all States that have explicit policies regarding exclusion of claims arising from intoxication apply those rules to health insurance. The coding displayed in the APIS comparison tables for this policy topic is limited to health insurance. Notes are provided for the few States with provisions that apply to accident insurance but not health insurance.

Similar State policies for motor vehicle coverage are addressed in the APIS policy topic on Vehicular Insurance: Losses due to Intoxication.

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[1] 1950 Proceedings of the National Association of Insurance Commissioners, 81st Annual Session, June 13, 1950; Québec, Canada. Kansas City, MO: National Association of Insurance Commissioners, 1950-2, 161, 950. 1950 NAIC Proc. 398.

Expander Explanatory Notes and Limitations for Health Insurance: Losses Due to Intoxication ("UPPL")

Explanatory Notes and Limitations Specifically Applicable to Health Insurance: Losses Due to Intoxication ("UPPL")

  1. Insurers in jurisdictions that have not enacted insurance exclusion provisions may still be able to exclude coverage for losses due to intoxication without explicit legislative permission. The legality of this type of action would have to be determined by State courts. Our research has not addressed this possibility.
     
  2. The APIS treatment of Insurers' Liability for Losses Due to Intoxication ("UPPL") does not include statutory or regulatory provisions related to the following:

    • Exclusion of coverage in credit disability plans (plans offered to eligible debtors) based on sickness or injury related to the use of alcoholic beverages.               
    • Exclusion of coverage for alcoholism treatment in long-term care policies, Medicare supplemental insurance policies, group or blanket disability insurance policies, or accident and health insurance policies. For more information, see the Health Insurance Parity APIS policy topic.
    • Exclusions or requirements for coverage for alcoholism treatment in short-term nursing home insurance policies or group health plans.
    • Exclusions of coverage for medical conditions or injuries caused in the commission of a crime.
       
  3. State laws pertaining to this policy topic include both statutory and regulatory provisions. Because detailed and comparable information on historical regulations is only available from January 1, 2003 forward, it is possible that APIS coverage of historical data for this policy topic is incomplete. However, any gaps in APIS coverage are limited to regulations that were in effect on or after January 1, 1998, but repealed before January 1, 2003. If a regulation was in effect on January 1, 2003, it is included in the APIS data, including its date of promulgation.
     
  4. It is possible that insurers exclude coverage through insurance provisions that do not specifically address alcohol intoxication or alcoholism. For example, an insurance contract might exclude coverage for injuries caused by the insured's own negligence or reckless behavior without specifying alcohol intoxication as a form of negligence or recklessness.
     
  5. We have not examined the potential impact of alcohol intoxication or alcoholism on other forms of insurance or insurance-like mechanisms, such as Workers' Compensation.
     
  6. Some jurisdictions that permit exclusion of intoxication-related claims, nonetheless provide an explicit exception for insurance coverage of alcoholism treatment (i.e., insurance exclusion does not permit denial of alcoholism treatment benefits). Other jurisdictions with insurance exclusion provisions but without such an exception may nonetheless require coverage for alcoholism treatment through other statutory or regulatory provisions or through administrative or court interpretation. (See Health Insurance Parity for Alcohol-Related Treatment for related information.)
     
  7. The National Conference of Insurance Legislators has announced its support for repeal of insurance exclusion laws.[1]  This suggests that States may review their insurance exclusion laws in the future.

Explanatory Notes and Limitations Applicable to All APIS Policy Topics

  1. State law may permit local jurisdictions to impose requirements in addition to those mandated by State law. Alternatively, State law may prohibit local legislation on this topic, thereby preempting local powers. APIS does not document policies established by local governments. 
     
  2. In addition to statutes and regulations, judicial decisions (case law) also may affect alcohol-related policies. APIS does not review case law except to determine whether judicial decisions have invalidated statutes or regulations that would otherwise affect the data presented in the comparison tables. 
     
  3. APIS reviews published administrative regulations. However, administrative decisions or directives that are not included in a State's published regulatory codes may have an impact on implementation. This possibility has not been addressed by the APIS research. 
     
  4. Statutes and regulations cited in tables on this policy topic may have been amended or repealed after the specific date or time period specified by the site user's search criteria. 
     
  5. A comprehensive understanding of the data presented in the comparison tables for this policy topic requires examination of the applicable Row Notes and Jurisdiction Notes, which can be accessed from the body of the table via links in the Jurisdiction column. 

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[1] Resolution in Support of Amending the NAIC Uniform Accident and Sickness Policy Provision Law, adopted March 2, 2001, as amended, February 21, 2003, National Conference of Insurance Legislators, http://ncoil.org/other/ses10.htm.
 

Expander Federal Law for Health Insurance: Losses Due to Intoxication ("UPPL")

(Policies in effect on: 1/1/2013) 

Our research identified no relevant Federal statutes pertaining to insurers' liability for losses due to intoxication. 

 

Expander Selected References for Health Insurance: Losses Due to Intoxication ("UPPL")

  1. Buhite, R.S., and Marrero-Ladik, H.M. Drugs, alcohol, and accidental death coverage. Tort Trial & Insurance Practice Law Journal 39(4):985-1010, 2004.
     
  2. Cochran, G. Analysis of the Uniform Accident and Sickness Policy Provision Law: Lessons for Social Work Practice, Policy, and Research. Social Work in Health Care 49(7):647-668, 2010.
     
  3. Fornili, K., and Goplerud, E. Trauma centers and insurance exclusion laws: Unintended consequences and missed opportunities. Journal of Addictions Nursing 17:193-198, 2006.
     
  4. Gentilello, L.M., Donato, A., Nolan, S., Mackin, R.E., Liebich, F., Hoyt, D.B., and LaBrie, R.A. Effect of the Uniform Accident and Sickness Policy Provision Law on alcohol screening and intervention in trauma centers. Journal of Trauma 59:624–631, 2005.
     
  5. National Highway Traffic Safety Administration. Developing Best Practices of Emergency Care of the Alcohol-Impaired Patient: Recommendations from the National Conference. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2000. Publication DOT HS 809 281.
     
  6. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Screening for Alcohol Problems - An Update. Alcohol Alert No. 56. Rockville, MD: NIAAA, 2002.
     
  7. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Alcohol and Trauma. Alcohol Alert No. 3. Rockville, MD: NIAAA, 1989.
     
  8. O'Keeffe, T., Shafi, S., Sperry, J.L., and Gentilello, L.M. The implications of alcohol intoxication and the Uniform Policy Provision Law on trauma centers: A national trauma data bank analysis of minimally injured patients. Journal of Trauma and Acute Care Surgery 66(2):495-8, 2009.
     
  9. Smothers, B.A., Yahr, H.T., and Ruhl, C.E. Detection of alcohol use disorders in general hospital admissions in the United States. Archives of Internal Medicine 164(7):749-756, 2004.
     
  10. Teitelbaum, J., Resenbaum, S., and Goplerud, E. State laws permitting intoxication exclusions in insurance contracts: Implications for public health policy and practice. Law and the public's health. Public Health Reports 119:585-587, 2004.

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