Conn. Doctors Hit Policy Exclusions for Alcohol-Related Injuries

April 18, 2006

Eight years ago, then-18-year-old Oliver Bishop IV made a costly mistake.

The Guilford, Conn. teen bought a case of beer and a half-pint of liquor and visited numerous parties. Though he had a designated driver that night, Bishop still got into his pickup truck, drove off the road and collided with a stone wall and two trees.

Bishop was treated at Yale-New Haven Hospital for extensive injuries, including two broken femurs, a broken hip, arm and nerve damage. He was in coma for 23 days.

Because his blood alcohol level was .165 percent alcohol by weight, Bishop’s insurance carrier, National Health Insurance Co., refused to cover the $242,235 medical bills he accumulated.

Bishop and his father, Oliver Bishop III, did not know about an exclusion written into the elder Bishop’s insurance policy denying coverage if an injury resulted from being under the influence of alcohol or a narcotic not prescribed by a physician.

A federal appeals court in 2003 upheld the insurance carrier’s decision.

“I would never have gone out and purchased a health insurance policy if I had been aware there was an alcohol exclusion in it,” said the elder Bishop, who is self-employed. “We purchased this health insurance policy to protect my family and it was not a cheap policy. We were paying hundreds of dollars a month to cover any and everything and it just didn’t happen.”

A group of physicians is asking the Connecticut legislature to prohibit such insurance exclusions. A bill making its way through the committee process would end exclusions in health insurance policies for alcohol use.

Dr. Mark Kraus, a Waterbury internist and chairman of the Connecticut State Medical Society’s committee on addiction medicine, said many physicians are reluctant to test injured patients for alcohol because they fear the insurance company will refuse to cover the bill, leaving the patient to pay for an expensive emergency room visit.

That means patients don’t receive alcohol counseling while in the hospital — interventions that oftentimes prove fruitful and prevent readmissions to the hospital.

According to Ensuring Solutions, 40 percent of injured patients have alcohol in their bloodstream when they are admitted to a trauma center.

“People who come to the emergency room department should be screened and should have some brief intervention, minimally,” Kraus said. “It seems that we have to make a decision because the private sector is again shirking their responsibility on the public sector and someone is paying for it.”

Efforts to repeal or prohibit alcohol exclusions are being considered in four other states this year, according to the “Ensuring Solutions to Alcohol Problems” program at George Washington University Medical Center in Washington, D.C. Colorado Gov. Bill Owens signed a law earlier this month banning the exclusions. Lawmakers in Hawaii are considering similar legislation, while bills failed in Illinois and Wyoming.

The first alcohol exclusions were adopted nearly 60 years ago when the National Association of Insurance Commissioners drafted a model law to discourage drinking. In 2001, however, the association voted to recommend repealing the exclusion laws.

Such laws are on the books in 35 states. Eight states, including Connecticut, never adopted them but do not explicitly prohibit insurance companies from excluding coverage for injuries suffered under the influence of alcohol or drugs. Since 2001, seven states have repealed or amended their exclusion laws, according to Ensuring Solutions.

The Senate and House co-chairmen of the Connecticut legislature’s insurance committee say they believe the bill has enough support to pass this year. It appears most health insurance policies — particularly group plans — already cover the injuries, said Sen. Joseph Crisco Jr., D-Woodbridge, and Rep. Brian O’Connor, D-Clinton.

A spokeswoman for Anthem Blue Cross and Blue Shield, one of the larger insurers in Connecticut, says her company does not exclude coverage for injuries suffered by intoxicated people. However, the company is not backing the bill.

“Senate Bill 425 is a mandate, and in general, Anthem Blue Cross and Blue Shield in Connecticut does not support mandates,” spokeswoman Karin A. Nobile said.

Meanwhile, Oliver Bishop’s hospital bill remains unpaid. John F. Wynne Jr., his lawyer, said the Bishops sued and settled with the insurance agent who issued the original policy, arguing he did not fully inform them of the exclusion. But that agent’s insurer has since filed for bankruptcy, putting the settlement in limbo.

The elder Bishop said insurance consumers, especially those with teenagers, need to read the fine print of their policies.

“This kid was 18 years old at the time. He was a ‘B’ student. He was captain of his wrestling team. He was an Eagle Scout. This was not a bad kid,” Bishop said.”‘If it happened to my son, it can happen to anybody.”

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