A medical provider has received an insurance denial due to a policy exclusion for self-inflicted injury. The patient was treated in the emergency room for the injury and then transferred to psychiatric care. To review the correctness of this action, the provider’s office obtained a copy of the carrier’s policy exclusion. The policy exclusion merely listed “self-inflicted injuries” under a list of exclusions for which a claim can be denied.
The medical provider notified the carrier that the emergency room treatment was the only treatment relating to the self-inflicted injury. The remainder of the treatment was for the psychiatric condition which prompted the patient to inflict the injury. Some policy exclusions for treatment related to self-inflicted injuries are broadly worded to include all treatment subsequent to the injury.
However, the provider appealed the denial because the applicable exclusion only pertained to treatment related to the injury itself and did not prohibit payment of subsequent psychiatric care. As a result, the carrier overturned the previous decision and paid the portion of the claim related to the psychiatric care.
In any such appeal, first obtain a copy of the exclusion to verify that the exclusion does exist and does pertain to the treatment in question. Submit any documentation which indicates that the care would not fall under the defined exclusion.
Application for your Facility
Many such policy exclusions indicate that no benefits will be paid for a self-inflicted injury, caused by the insurer while sane or insane. According to the Insurance – Suicide – Sane or Insane in the American Law Review, the courts have reached widely opposed results in interpreting suicide exclusions which contain the term, “while sane or insane.” Many courts have refused to hold the insured responsible for any act which was performed in a mental state where the person was not able to comprehend the physical nature and consequences of the destructive act. Several courts have held that the lack of such comprehension is immaterial and that recovery is barred if the act committed was of such a character that if performed by a sane person, it would have been regarded as suicidal.
Check your state insurance code for specific legislation which governs the insurance company’s ability to deny treatment. If the injury was related to a domestic disturbance, you might want to see if your state has mandated coverage for domestic disputes. If so, you might want to quote such information in your appeal letter.
Other cases helpful in overturning suicide/self-inflicted injury denials:
Shelby County Health Care Corporation dba Regional Medical Center v Whitten, CCH Life Cas par. 3350, 1996 WL 482670 (Tenn. App. 1996). An insured shot herself in the mouth. In an action for medical benefits under a policy which had an exclusion for “self-inflicted injury”, a judgment for defendant insurer as a matter of law was reversed on appeal. The fact that the injuries were self-inflicted did not preclude the harm from being deemed accidental if, at the time of the accident, the insured could not expect or foresee the possibility of injury. The insured’s mental illness, and a psychiatrist’s testimony that she was insane at the time of injury, raised a factual issue whether she foresaw or could have foreseen that her death or injury might result from her act, and whether her injury was by accident.
Martin v Oklahoma Farmers Union (1981, Okla) 622 P2d 1078. The suicide clause was held not a defense where the insured died from self-inflicted injuries but did not intend to kill himself.
Skaggs v Aetna Life Ins. Co. (1994, Mo App) 605 SW2d 45. Summary judgment for the insurer was reversed in a claim for accidental death benefits where the insured committed suicide. Under Missouri law, suicide while sane is not an accident but suicide while insane is an accident. The widow’s testimony that the insured suffered depression, was unable to recover from the death of his mother, and had severe headaches and a drinking problem raised a genuine issue of material fact as to whether he was sane when he committed suicide.
Leave A Response